Juvenile bipolar disorder

Shared and distinct white matter abnormalities in adolescent-onset schizophrenia and adolescent-onset psychotic bipolar disorder

BACKGROUND

While adolescent-onset schizophrenia (ADO-SCZ) and adolescent-onset bipolar disorder with psychosis (psychotic ADO-BPD) present a more severe clinical course than their adult forms, their pathophysiology is poorly understood. Here, we study potentially state- and trait-related white matter diffusion-weighted magnetic resonance imaging (dMRI) abnormalities along the adolescent-onset psychosis continuum to address this need.

METHODS

Forty-eight individuals with ADO-SCZ (20 female/28 male), 15 individuals with psychotic ADO-BPD (7 female/8 male), and 35 healthy controls (HCs, 18 female/17 male) underwent dMRI and clinical assessments. Maps of extracellular free-water (FW) and fractional anisotropy of cellular tissue (FAT) were compared between individuals with psychosis and HCs using tract-based spatial statistics and FSL's Randomise. FAT and FW values were extracted, averaged across all voxels that demonstrated group differences, and then utilized to test for the influence of age, medication, age of onset, duration of illness, symptom severity, and intelligence.

RESULTS

Individuals with adolescent-onset psychosis exhibited pronounced FW and FAT abnormalities compared to HCs. FAT reductions were spatially more widespread in ADO-SCZ. FW increases, however, were only present in psychotic ADO-BPD. In HCs, but not in individuals with adolescent-onset psychosis, FAT was positively related to age.

CONCLUSIONS

We observe evidence for cellular (FAT) and extracellular (FW) white matter abnormalities in adolescent-onset psychosis. Although cellular white matter abnormalities were more prominent in ADO-SCZ, such alterations may reflect a shared trait, i.e. neurodevelopmental pathology, present across the psychosis spectrum. Extracellular abnormalities were evident in psychotic ADO-BPD, potentially indicating a more dynamic, state-dependent brain reaction to psychosis.

Elevated Epidermal Growth Factor (EGF) as Candidate Biomarker of Mood Disorders-Longitudinal Study in Adolescent and Young Adult Patients

Bipolar disorder (BD) is a chronic mental disorder that affects more than 1% of the population worldwide. Over 65% of patients experience early onset of the disease. Most cases of juvenile bipolar disorder begin with a depressed mood episode, and up to 50% of youth initially diagnosed with major depression go onto developing a BD. Our study aimed to find biomarkers of diagnosis conversion in young patients with mood disorders. We performed a two-year follow-up study on 79 adolescent patients diagnosed with MDD or BD, with a detailed clinical assessment at five visits. We monitored diagnosis change from MDD to BD. The control group consisted of 31 healthy youths. According to the neurodevelopmental and neuroimmunological hypotheses of mood disorders, we analyzed serum levels of brain-derived neurotrophic factor (BDNF), proBDNF, epidermal growth factor (EGF), migration inhibitory factor (MIF), stem cell factor (SCF), and correlations with clinical factors. We detected a significant disease-dependent increase in EGF level in MDD and BP patients at baseline exacerbation of depressive or hypomanic/manic episodes as well as in euthymic state compared to healthy controls. No potential biological predictors of disease conversion were found. Replication studies on a larger cohort of patients are needed.

Characteristics Associated with Depression Severity in 270 Juveniles in a Major Depressive Episode

Introduction: Severe depression is prevalent in young persons and can lead to disability and elevated suicidal risk. Objectives: To identify clinical and demographic factors associated with the severity of depression in juveniles diagnosed with a major mood disorder, as a contribution to improving clinical treatment and reducing risk of suicide. Methods: We analyzed factors associated with depression severity in 270 juveniles (aged 6-18 years) in a major depressive episode, evaluated and treated at the Bambino Gesù Children's Hospital of Rome. Depressive symptoms were rated with the revised Children's Depression Rating Scale (CDRS-R) and manic symptoms with the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) Mania Rating Scale (K-SADS-MRS). Bivariate comparisons were followed by multivariable linear regression modeling. Results: Depression severity was greater among females than males (55.0 vs. 47.2), with the diagnosis of a major depressive disorder (MDD) vs. bipolar disorder (BD; 53.8 vs. 49.3), and tended to increase with age (slope = 1.14). Some symptoms typical of mania were associated with greater depression severity, including mood lability, hallucinations, delusions, and irritability, whereas less likely symptoms were hyperactivity, pressured speech, grandiosity, high energy, and distractibility. Factors independently and significantly associated with greater depression severity in multivariable linear regression modeling were: MDD vs. BD diagnosis, female sex, higher anxiety ratings, mood lability, and irritability. Conclusions: Severe depression was significantly associated with female sex, the presence of some manic or psychotic symptoms, and with apparent unipolar MDD. Manic/psychotic symptoms should be assessed carefully when evaluating a juvenile depressive episode and considered in treatment planning in an effort to balance risks of antidepressants and the potential value of mood-stabilizing and antimanic agents to decrease the severity of acute episodes and reduce suicidal risk.

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.

Nursing children and adolescents with bipolar disorder: assessment, diagnosis, treatment, and management

TOPIC

The role of the mental health nurse in the assessment, diagnosis, treatment, and management of children and adolescents with bipolar disorder in community and hospital settings.

PURPOSE

In many areas of clinical practice, mental health nurses have more contact with service users than any other professional group. They are therefore well placed to support children and adolescents with bipolar disorder during first contact with primary care services, through engagement with specialist mental health services, and in accessing early intervention and crisis services. This paper summarizes the contribution that child and adolescent mental health nurses make to the care of children and adolescents with bipolar disorder.

SOURCES

This paper is based on evidence from systematic reviews; meta-analyses and best practice evidence from CINAHL; EMBASE; MEDLINE, PsychINFO; Cochrane Collaboration; National Institute for Health and Clinical Excellence; National Collaborating Centre for Mental Health; NHS Centre for Reviews and Dissemination; Oxford Centre for Evidence Based Medicine; United States Agency for Healthcare Research and Quality.

CONCLUSIONS

Child and adolescent mental health nurses work with children and adolescents who have bipolar disorder in a range of settings. These include community mental health services, hospitals, and schools. Due to the multidisciplinary nature of the treatment and management of bipolar disorder during childhood and adolescence, nurses have a major role to play in providing frontline assessment services, monitoring treatment, and delivering psychosocial interventions.

Long-chain omega-3 polyunsaturated fatty acids in the blood of children and adolescents with juvenile bipolar disorder

Reduced long-chain omega-3 polyunsaturated fatty acids (LCn-3PUFA), including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), have been reported in adult patients suffering from depression and bipolar disorder (BD). LCn-3PUFA status has not previously been examined in children and adolescents with BD compared with healthy controls. Fifteen children and adolescents (9-18 years, M +/- SD = 14.4 +/- 3.48) diagnosed with juvenile bipolar disorder (JBD) and fifteen healthy age and sex-matched controls were assessed for dietary intake and fasting red blood cell (RBC) membrane concentrations of LCn-3PUFA. Fatty acid concentrations were compared between participants diagnosed with JBD and controls after controlling for dietary intake. RBC membrane concentrations of EPA and DHA were not significantly lower in participants diagnosed with JBD compared with healthy controls (M +/- sem EPA = 3.37 +/- 0.26 vs. 3.69 +/- 0.27 microg/mL, P = 0.458; M +/- sem DHA = 22.08 +/- 2.23 vs. 24.61 +/- 2.38 microg/mL, P = 0.528) after controlling for intake. Red blood cell DHA was negatively (r = -0.55; P = 0.044) related to clinician ratings of depression. Although lower RBC concentrations of LCn-3PUFA were explained by lower intakes in the current study, previous evidence has linked reduced LCn-3PUFA to the aetiology of BD. As RBC DHA was also negatively related to symptoms of depression, a randomised placebo-controlled study examining supplementation with LCn-3PUFA as an adjunct to standard pharmacotherapy appears warranted in this patient population.

ECNP consensus meeting. Bipolar depression. Nice, March 2007

DSM-IV, specifically its text revision DSM-IV-TR, remains the preferred diagnostic system. When employed in general population samples, prevalence estimates of bipolar disorder are relatively consistent across studies in Europe and USA. In community studies, first onset of bipolar mood disorder is usually in the mid-teenage years and twenties, and the occurrence of a major depressive episode or hypomania is usually its first manifestation. Since reliable criteria for delineating unipolar (UP) and bipolar (BI) depression cross-sectionally are currently lacking, there is a longitudinal risk - probably over 10% - that initial UP patients ultimately turn out as BP in the longer run. Its early onset implies a severe potential burden of disease in terms of impaired social and neuropsychological development, most of which is attributable to depression. BIPOLAR DEPRESSION IN CHILDREN: Bipolar I disorder is rare in prepubertal children, when defined according to unmodified DSM-IV-TR criteria. A broad diagnosis of bipolar disorder risks confounding with other childhood psychopathology and has less predictive value for bipolar disorder in adulthood than the conservative definition. Nevertheless, empirical studies of drug and other treatments and longitudinal studies to assess validity of the broadly defined phenotype in children and adolescents are desirable, rather than extrapolation from adult bipolar practice. The need for an increased capacity to conduct reliable trials in children and adolescents is a challenge to Europe, whose healthcare system should allow greater participation and collaboration than other regions, via clinical networks. ECNP will aspire to facilitate such developments. BIPOLAR DEPRESSION IN ADULTS - UNIPOLAR/BIPOLAR CONTRAST: Despite some differences in symptom profiles and severity measures, a cross-sectional categorical distinction between bipolar (BP) and unipolar (UP) depression is currently impossible. For regulatory purposes, a major depressive episode, meeting DSM-IV-TR criteria, remains the same diagnosis, irrespective of the overall course of the disorder. However, in refining diagnosis in future studies and DSM-V, a probabilistical approach to the UP/BP distinction is more likely to be informative as recommended by the International Society for Bipolar Disorders (ISBD). Anxiety is a commonly present, often at syndromal levels, in bipolar populations. Thus, RCT inclusion criteria for trials not targeting anxiety, should accept co-morbid anxiety disorders as part of the history and even current anxiety symptoms, where these are not dominating the mental state at recruitment to a study. Rapid cycling patients defined as those suffering from 4 or more episodes per year, may also be recruited into trials of bipolar depression without impairing assay sensitivity. Illness severity critically affects assay sensitivity. The minimum scores for entry into a bipolar depression trials should be >20 on HAM-D (17 item scale). However, efficacy is best detected in patients with HAM-D >24 at baseline. THE USE OF RATING SCALES IN BIPOLAR DEPRESSION: There is some dissatisfaction with the HAM-D or MADRS as the preferred primary outcome for trials, although they probably capture global severity adequately. Secondary measures to capture so-called atypical symptoms (such as hypersomnia or hyperphagia), or specific psychopathology more common in bipolar participants (such as lability of mood), could be informative as secondary measures. TREATMENT STUDIES IN BIPOLAR DEPRESSION: Monotherapy trials against placebo remain the gold-standard design for determining efficacy in bipolar depression. The confounding effects of co-medication are emerging from the literature on antidepressant studies in bipolar depression, often conducted in combination with antimanic agents to avoid possible switch to mood elevation. Three arm trials, including the compound to be tested, placebo, and a standard comparator, are generally preferred in order to ensure assay sensitivity and a better picture of benefit-risk ratio. However, in the absence of any gold-standard, two-arm trials may be enough. If efficacy happens to be proven as monotherapy, new compounds may be tested in adjunctive-medication placebo-controlled designs. Younger adults, without an established need for long-term medication, may be particularly suitable for clinical trials requiring placebo controls. The conversion rate of initial UP depression, converting to become BP in the long run is estimated to be 10%. Switch to mania or hypomania may be the consequence of active treatment for bipolar depression. Some medicines such as the tricyclic antidepressants and venlafaxine may be more likely to provoke switch than others, but this increased rate of switch may not be seen until about 10 weeks of treatment. Twelve week trials against placebo are necessary to determine the risk of switch and to establish continuing effects. Careful assessment at 6-8 weeks is required to ensure that patients who are failing to respond do not continue in a study for unacceptable periods of time. To capture a switch event, studies should include scales to define the phenomenology of the event (e.g. hypomania or mania) and its severity. These may be best applied shortly after the clinical decision that switch is occurring. Long-term treatment is commonly required in bipolar disorder. Trials to detect maintenance of effect or continued response in bipolar depression should follow a 'relapse prevention' design: i.e. patients are treated in an index episode with the medicine of interest and then randomized to either continue the active treatment or placebo. However, acute withdrawal of active medication after treatment response might artificially enhance effect size due to active drug withdrawal effects. A short taper is usually desirable. Longer periods of stabilisation are also desirable for up to 3 months: protocol compliance may then be difficult to achieve in practice and so will certainly make studies more difficult and expensive to conduct. The addition of a medicine to other agents during or after the resolution of a depressive or manic episode, and its subsequent investigation as monotherapy against placebo to prevent further relapse (as in the lamotrigine maintenance trials) is clinically informative. Assay sensitivity and patient acceptability are enhanced if the outcome in long-term studies is 'time to intervention for a new episode' for discontinuation designs.

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.

Cognitive-behavioral therapy for bipolar disorders in adolescents: a pilot study

OBJECTIVES

To develop a cognitive behavioral intervention for adolescents with bipolar disorders, test its feasibility and preliminary efficacy.

METHODS

Based on existing research, a manualized, individually delivered cognitive behavioral intervention was developed and tested with adolescents with bipolar disorders as an adjunct to pharmacological treatment. Using existing data, baseline characteristics and outcome were compared to a matched group of eight adolescents with bipolar disorders who did not receive any psychosocial intervention.

RESULTS

Preliminary results support the feasibility and efficacy of this manualized cognitive behavioral intervention.

CONCLUSIONS

Individually delivered cognitive-behavioral therapy (CBT) as an adjunct to pharmacological treatment is feasible and associated with symptom improvement in adolescents with bipolar disorders. Randomized controlled studies are needed.

Comorbidity of attention deficit hyperactivity disorder in juvenile bipolar disorder

OBJECTIVE

There is some evidence to suggest that attention deficit hyperactivity disorder (ADHD) and juvenile bipolar disorder could be related. This is based on studies of comorbidity and some preliminary family study data. However, doubts continue to be raised about the relationship between the two disorders. This study examined the comorbidity of disruptive behavior disorders (DBD) that include ADHD, oppositional defiant disorder (ODD) and conduct disorder (CD) in juvenile bipolar disorder.

METHOD

Seventy-three subjects with onset of bipolar disorder at age 18 years or younger were evaluated using structured interviews (Missouri Assessment of Genetics Interview for Children, Structured Clinical Interview for DSM-IV Axis I disorders--Clinician Version, and Operational Criteria Checklist for Psychotic Disorders version 3.4). Information was collected from subjects as well as from their parents. Patients with comorbid DBD were compared with patients without DBD.

RESULTS

Ten subjects (14%) had one or more comorbid DBD. ADHD, CD, and ODD were present in three (4%), two (3%), and eight (11%) subjects, respectively. Those with DBD had earlier onset of bipolar disorder and spent more time ill compared to those without DBD.

CONCLUSIONS

The rates of comorbid DBD in juvenile bipolar disorder are low. The study does not support a definite relationship between ADHD and juvenile bipolar disorder. Higher rates reported previously may be due to differing methods of subject ascertainment. Samples recruited from community and general psychiatric settings may help to clarify the relationship between bipolar disorder and ADHD.

Preschool-onset mania: incidence, phenomenology and family history

OBJECTIVE

To ascertain the incidence of mania among preschool children presenting in a community mental health clinic over a 24-month period, to describe the signs and symptoms of the children meeting criteria for mania and present their family histories based on systematic diagnostic interview.

METHODS

Forty children less than the age of 5 years presented between October 2001 and September 2003. Signs of mania were determined using a structured interview. Family history was determined via live, structured interview of parents. Those meeting the criteria for major depressive disorder (MDD) or bipolar disorder (BP) were classified as having mood disorder.

RESULTS

Eleven of the 40 children (27.5%) met the criteria for mania, of which only 3 (27.3%) were mixed manic. Symptoms often included "classic" mania features (i.e. euphoric, elated mood), despite co-existing features of attention-deficit hyperactivity disorder (ADHD)--such as incessant, chaotic, even frenetic motor activation--in all of them. Seven of the 11 (63.6%) had at least one parent with BP and a total of 8 (72.7%) had a parental history of affective illness when parents with MDD were counted. One child without a first-degree relative with BP had a second degree relative with this illness. Thus, 8 of 11 (72.7%) had a relative with BP, and 9 (81.8%) a family history of mood disorder (counting both MDD and BP).

LIMITATION

Open case series.

CONCLUSION

There was a surprisingly high incidence of mania with classical features in this population. The family history data strongly support the view that these children have BP. Preschool mania appears to be strongly linked to the presence of familial affective illness. Admittedly, preschool mania is a controversial topic, and data from other centers is needed to further characterize its clinical and familial features.

A prospective 4-5 year follow-up of juvenile onset bipolar disorder

OBJECTIVE

Data on outcome of juvenile onset bipolar disorder is limited. This study examined the course and outcome of bipolar disorder and assessed the rate and predictors of recovery and relapse in a sample of children and adolescents over a 4-5 year period.

METHOD

Twenty-five consecutively ascertained subjects (9-16 years) with a diagnosis of mania (mean duration at intake of 4.6 +/- 3.9 weeks), were comprehensively assessed at baseline and at 6-month intervals using the Diagnostic Interview for Children and Adolescents (revised) (DICA-R), the Missouri Assessment for Genetic Interview in Children (MAGIC), the Young's Mania Rating Scale (YMRS) and the Children's Global Assessment (CGAS). The study phenotype required DSM-IV criteria of mania with elation and/or grandiosity as a criterion to distinguish them from those with attention deficit hyperactivity disorder. Subjects received the standard treatment as prescribed by their primary treating team.

RESULTS

During the course of the study period, all 25 subjects (100%) recovered from the index episode. The mean time to recovery was 44 +/- 46 days. The mean duration of follow-up was 51.6 +/- 4.1 months. Sixteen subjects (64%) relapsed after a mean period of 18 +/- 16.4 months. A majority of the relapses (72.4%) were while the subjects were on treatment.

CONCLUSIONS

Acute juvenile onset mania has a high rate of recovery and low chronicity. The relapse rate was high and most of these occurred in the first 3 years despite aggressive prophylactic treatment. The effectiveness of currently used thymoleptics, in particular lithium, in the prophylaxis of juvenile bipolar disorder needs to be evaluated in controlled studies.

The index manic episode in juvenile-onset bipolar disorder: the pattern of recovery

OBJECTIVE

Recent studies of patients with juvenile bipolar disorder report low rates of recovery and high rates of chronicity. However, we lack data on the short-term outcome. This study examines the pattern of recovery from the index episode in an aggressively treated juvenile sample.

METHOD

We assessed 25 subjects (< 16 years) with a diagnosis of mania, using the Diagnostic Interview for Children and Adolescents-Revised) (DICA-R), Young Mania Rating Scale (YMRS), and Children's Global Assessment Scale (CGAS) at intake and at 3 and 6 months. We studied the time taken to recover from the index episode, the level of functioning, and the factors predicting them.

RESULTS

After 6 months, 24 (96%) subjects had recovered from the index manic episode. The median time to recovery was 27 days. Total episode length was significantly longer among those with previous affective episodes.

CONCLUSIONS

The findings suggest that juvenile-onset mania has high rates of recovery and low rates of chronicity. These differences from the existing literature need further exploration.

Unsuspected depressive mania in pre-pubertal Hispanic children referred for the treatment of 'depression' with history of social 'deviance'

BACKGROUND

Despite an emerging Literature on the mixed nature of pediatric mania, initial presentation with conduct problems continues to mislead mental health clinicians. The present report focuses on Hispanic pre-pubertal children referred for the treatment of depression in the context of conduct problems.

METHODS

Eleven boys and two girls received a structured psychiatric assessment in a practice setting to make sense of the presenting clinical complexity. Diagnoses were assigned using the DSM-IV criteria.

RESULTS

Ten of the boys and both girls met criteria for depressive mania. Their family histories were replete with affective disorder. Five (50%) of the boys and both of the girls (100%) with depressive mania had family histories of bipolar disorder. Six (60%) of the boys and neither of the girls with depressive mania had psychotic features. Those with depressive mania exhibited clear-cut circadian changes in symptomatology. Euphoria, oscillating with affective states indicative of psychic pain, was characteristically restricted to the evenings or nighttime. However, the drive to seek treatment had stemmed from social 'deviance'.

CONCLUSION

Children with depressive mania are often unrecognized in clinical settings. Boys with conduct problems may be disproportionately represented among such children. These data support Akiskal's hypothesis that externalizing (conduct) problems in clinically referred children with depression are indicative of bipolar disorder.

The pharmacologic treatment of the early phase of first-episode psychosis in youths

OBJECTIVES

To summarize available knowledge about pharmacologic treatments that are used for first-onset (or early) psychosis in youths, with particular consideration of the prodromal stage and the effectiveness and safety of novel antipsychotic drugs and mood stabilizers.

METHOD

A computerized search of medical databases (for example, Medline and Embase), a manual searching of articles and textbooks, and the use of vignettes to highlight treatment issues.

RESULTS

There are limited data about the effectiveness and safety of psychotropic agents for youths with psychosis and scarce information about the drug treatment of the prodromal stage of early psychosis in all age groups. The available data are encouraging, although the newer agents are not without safety concerns.

CONCLUSIONS

Despite the paucity of studies, there is a range of psychotropics that may be used in the early stages of psychotic illness in youths. Drug choice is influenced by several factors, including the clinical picture, side effect profile, and patient preference. In certain situations, the decision may be not to use medication.