A symposium at the 2012 meeting of the American Academy of Child and Adolescent Psychiatry (AACAP) examined long-term outcomes of childhood onset disorders, including bipolar disorder, unipolar depression, ADHD, and anxiety disorder.
Course of Childhood Onset Anxiety Disorders
Danny Pine presented a study of 191 adolescents with an anxiety disorder, among whom 36% showed no anxiety disorder in adulthood, while 62% continued to have an anxiety disorder. Among a control population, 390 adolescents without an anxiety disorder remained so in adulthood, while 36 developed new onset of an anxiety disorder in adulthood. Sixty-two of the 98 participants who had anxiety disorders in adulthood had had the disorder continuously from its onset in adolescence. Thus, it appears that approximately two-thirds of adults with an anxiety disorder show a persistence of their childhood onset anxiety disorder, while approximately 1/3 had a new anxiety disorder diagnosis.
Editor’s Note: While all 4 of these major childhood onset psychiatric illnesses (bipolar, unipolar, ADHD, and anxiety disorders) show long term difficulties into adulthood in the majority of instances, it appears that the most severely impacted are those with bipolar disorder. These data are also consistent with retrospective data from multiple cohorts of adults with bipolar disorder, which indicate that those whose illness began in childhood fared more poorly in adulthood than those with adult-onset illness. Thus, while there has been a modicum of treatment research in childhood depression and anxiety disorder and a plethora of treatment studies in ADHD, the dearth of treatment studies in children with bipolar disorder is all the more disconcerting.
Bipolar disorder is common, occurring in some 2 to 3% of children and adolescents, and carries a relatively grave prognosis into adulthood in the majority of instances, especially when it is inadequately treated. Virtually all of the investigators in the area of childhood-onset bipolar who presented at the AACAP meeting have pleaded for increased treatment research for bipolar disorder in children, and one can only hope that their message is soon heard.
Anxiety and Depressive Disorders Often Precede the Onset of Bipolar Disorder in Those At High Risk Due to Family History
At the 2012 meeting of the American Academy of Child and Adolescent Psychiatry (AACAP) meeting, Anne Duffy and Gabrielle A. Carlson sponsored a symposium on the association between anxiety and minor mood disorders and subsequent bipolar disorder in those at high risk. Researchers presenting at the symposium consistently found that there is a sequence in which young people at high risk for bipolar disorder develop increasingly severe illnesses: first anxiety, then mood disorders, then bipolar illness.
One difference: the incidence of childhood-onset bipolar disorders in those at high risk because a parent has the disorder was lower in Canada, Switzerland, and the Netherlands than it was in the US.
Duffy, a professor of psychiatry in Calgary, noted that bipolar disorder is highly heritable even though most adults with bipolar illness do not have a family history of bipolar illness among their first-degree relatives. She shared estimates that if one parent has bipolar disorder their offspring have a 5% lifetime risk of developing bipolar disorder. If both parents have bipolar disorder their offspring have a 25% risk of developing bipolar disorder and a 35% incidence of developing any affective disorder (although other data by Lapalme et al. suggest it may be as high as 60%).
Duffy found that when parents responded well to lithium, their children tended to do the same. Lithium-responsive patients tended to be those without anxiety disorder and substance abuse and who had classic bipolar episodes and clear well intervals between episodes. Read more
An article published by Braun et al. in Pediatrics last year suggests that children who were exposed to higher levels of BPA while in the womb exhibited more anxious and depressed behaviors and poorer emotional control and inhibition at age 3. Braun described the implications of this finding to Medscape Medical News:
“At this point, we don’t know what these findings mean in terms of clinical disorders of behavior,” Joe M. Braun, MSPH, PhD, from the Department of Environmental Health, Harvard School of Public Health, Boston, Massachusetts, told Medscape Medical News. “Future studies will need to determine if BPA exposures are associated with clinical behavior disorders,” he said.
BPA is used in a variety of consumer products, including dental sealants, food/beverage containers and linings, medical equipment, and thermal receipts, such as those from ATM machines. Virtually all people in industrialized nations are exposed to the plasticizer.
“People who are concerned about BPA exposure could decrease or eliminate their consumption of canned or packaged foods; they could also avoid contact with thermal receipts,” Dr. Braun said.
An article by Lori Altshuler et al. (including this editor Robert M. Post) published in the American Journal of Psychiatry in 2010 presents research that among bipolar patients studied over a period of 7 years, women spent more time than men depressed. Women had higher rates of rapid cycling and of anxiety disorders, both of which were associated to higher rates of depression.
In a study published in Neuropscyhopharmacology, three sessions of intravenous scopolamine (4µg/kg over 15 minutes) led to rapid antidepressant response in both men and women, but the magnitude of response was larger in women. Women also experienced significant reduction in anxiety, as seen below:
Editor’s Note: Scopolamine is a potent blocker of acetylcholine receptors of the muscarinic type. This can cause side effects such as dry mouth and constipation. However, when given intravenously, scopolamine produces rapid onset of antidepressant effects in both bipolar and unipolar depressed patients. This study suggests that the drug may be even more effective in women.
My Mood Monitor, a website for mental health screening, has introduced depressioncheck, a free, mobile version of their M-3 Checklist, a scientifically validated screening tool for mood and anxiety disorders that can now be used via Apple’s iPhone and iPod Touch. It can be found in the Itunes App Store.
Adapted from the online version, the mobile version provides a short series of questions that measure indicators of mental health. Developed by a team of mental health practitioners and experts, the checklist takes only three minutes to complete. It is ideal to fill out in the waiting room prior to an appointment with a general practitioner so the doctor can be made aware of potential problems in the area of mental health. Depressioncheck is appropriate for those 18 years and older and its accuracy was confirmed in an article published in the Annals of Family Medicine in March 2010.
We recommend My Mood Monitor and the new mobile application as simple and reliable screening tools that can assess the presence of unipolar and bipolar mood and anxiety disorders, including obsessive-compulsive disorder, panic disorder, and PTSD. Read more
In a double-blind, placebo-controlled trial for patients with bipolar disorder, Martin Alda and colleagues from Dalhousie University in Halifax, Nova Scotia found that the compound methylene blue was an effective augmentation for mood stablizers. Methylene blue inhibits nitric oxide synthetase and guanylate cyclase, the overproduction of which might be associated with neuronal damage. Since bipolar disorder has consistently been associated with neuronal and glial cell dysfunction and loss, methylene blue could be a promising treatment.
Methylene blue turns urine blue, so in place of a placebo the researchers used very low doses (15 mg daily) of methylene blue compared with the active dose of 195 mgs daily.
Thirty-seven patients were enrolled in the randomized 26-week trial, and all patients were treated with lamotrigine as their primary mood stabilizer and with any additional medications they were already taking. Patients entered in a well or euthymic state (n =20), mildly depressed (n=14), or while minimally cycling (n = 3).
Scores on both the Montgomery-Asberg Depression Rating Scale and the Hamilton Rating Scale for Depression improved significantly, with an effect size of 0.47 and 0.42, respectively. Hamilton Anxiety Rating Scale scores also improved significantly with an effect size of 0.46.
Methylene blue was well tolerated, with only transient and mild side effects observed. However, the FDA has issued a warning that using methylene blue with serotonin active agents can lead to a severe serotonin syndrome (because methylene blue is a potent inhibitor of MAO-A and will increase brain serotonin levels when used in conjunction with serotonin active antidepressants). Symptoms of serotonin syndrome can include confusion, hyperactivity, sweating, fever, shivering, diarrhea, trouble with coordination, and even seizures.
The researchers at Dalhousie University concluded that methylene blue used as an adjunctive medication to lamotrigine and other previously inadequately effective agents (only those which are NOT serotonin active) significantly improved depression and anxiety in patients with bipolar disorder. They proposed further exploration of the mechanisms involved in this change, with the possibility that other drugs with similar actions could also be effective in this disorder.
If you have unipolar depression or bipolar disorder and are having trouble stabilizing your mood, we recommend nightly charting of mood, medications and side effects on the easy-to-use Monthly Mood Chart Personal Calendar (pictured below) or the National Institute of Mental Health Life Chart (NIMH-LCM), both of which are available for download.
Click on the Life Charts tab above to download the personal calendar, which includes space for rating mood, functioning, hours of sleep, life events, side effects, and other symptoms such as anxiety. Then bring the chart to each visit with your physician to help in the assessment of treatments.
Life charting can help determine which medications are working partially and need to be augmented further, and which need to be eliminated because of side effects. Since there are now many potential treatments for depression and bipolar disorder (some FDA-approved and some not), a careful assessment of how well each new treatment works for a particular patient is essential to finding the optimal treatment regimen.
Generalized anxiety disorder (GAD) is a prevalent illness often associated with considerable discomfort and dysfunction. It often co-occurs with bipolar disorder. Traditional treatments of the primary syndrome (occurring in the absence of bipolar disorder) involve serotonin-selective antidepressants and serotonin-noradrenergic reuptake inhibitors such as venlafaxine (Effexor) or duloxitine (Cymbalta). While these are often useful and lead to considerable improvement, they often do not lead to full remission of somatic or accompanying symptoms of insomnia.
Alternative treatment possibilities include the anticonvulsant pregabalin (Lyrica), which has been found effective in four placebo-controlled studies in GAD. A poster presentation by Joshi et al. at the American Psychiatric Association meeting in San Francisco in May 2009 also reported that pregabalin was more effective in reducing sleep disturbance than venlafaxine. Pregabaline is FDA-approved for seizures and fibromyalgia, but not for GAD or pain syndromes. Another treatment possibility is quetiapine (Seroquel), where not only have there been positive efficacy in placebo-controlled studies of patients with GAD, but the patients also experienced improvement in sleep.