Characteristics of Youth with Bipolar Spectrum Disorders

October 5, 2020 · Posted in Diagnosis, Risk Factors · Comment 

In a 2020 article in the Journal of Child and Adolescent Psychopharmacology, researcher Gonzalo Salazar de Pablo and colleagues described characteristics of youth with three different bipolar spectrum disorders: bipolar I disorder, bipolar disorder not otherwise specified (NOS) and mood disorder (MD) not otherwise specified. The participants were hospitalized adolescents aged 12–18 years, who were highly impaired with hallucinations, delusions, incoherence, or inability to function.

Mania (especially irritability) and depressive symptoms were common in all three groups.

Many of the youths had comorbid conditions. Approximately 40% of each diagnosis group had an anxiety disorder. Attention deficit hyperactivity disorder (ADHD) was seen in 29.2% of those with bipolar I disorder, 34.5% of those with bipolar NOS, and 43.5% of those with mood disorder NOS. Oppositional defiant disorder was seen in just over 20% of those with bipolar I or bipolar NOS, and just over 30% of those with mood disorder NOS. Substance use disorders were seen in 8.3% of those with bipolar I and about 21% of those with bipolar NOS or mood disorder NOS. Many of the participants had moderate to severe suicidality.

The median delay before the adolescents received treatment for their moderate to severe symptoms was 21 to 25 weeks. After discharge from the hospital, the adolescents with bipolar I, bipolar NOS, and mood disorder NOS were typically treated with atypical antipsychotics (79.2%, 62.1%, and 56.5%, respectively), mood stabilizers (66.7%, 31.0%, and 34.8%), and lithium (58.3%, 20.7%, 30.4%), with greater use of mood stabilizers and lithium than on admission and less use of antidepressants. Few children were on ADHD medications on admission, and even fewer (4-9%) on discharge.

The authors conclude: “Youth with BD-I, BD-NOS, and MD-NOS experience considerable symptomatology and are functionally impaired, with few differences observed in psychiatric comorbidity and clinical severity. Moreover, youth with BD-NOS and MD-NOS undergo a [long] period with subthreshold manic symptoms, enabling identification and, possibly, preventive intervention of those at risk for developing [bipolar disorder] or other affective episodes requiring hospitalization.”

Editor’s Note: These findings replicate many others in the field indicating that children with bipolar spectrum disorders, even those with symptoms short of a full-blown bipolar I diagnosis, are highly impaired with multiple comorbidities and high levels of suicidality and other dangerous symptoms. These patients deserve systematic pharmacological intervention based on an extensive clinical treatment literature.

The only thing the authors failed to address is that not only does no such clinical treatment literature exist, but there does not seem to be any recognition by the National Institute of Mental Health and other funding bodies that a series of treatment-oriented studies in children and adolescents is urgently needed.

The 2010 epidemiological studies of Kathleen Merikangas and colleagues indicate that 2.2% of adolescents have a bipolar spectrum diagnosis and that 80% of those young people are not in any kind of treatment. This is in part driven by a lack of consensus about appropriate treatment. The magnitude and seriousness of this illness creating lifelong problems, disability, cognitive impairment, and the loss of more than a decade of life expectancy is a public health catastrophe.

In the 1980s, AIDS protesters had to raise awareness, protest, and clamor for treatment studies in a highly confrontational manner before AIDS research was appropriate funded. Anthony Fauci, Director of the National Institute of Allergy and Infectious Disease since 1984, has said he was finally convinced that the AIDS protestors were correct, and he then joined forces with them to foster and accelerate treatment studies. The prognosis for AIDS changed from certain death in the 1980s to a manageable illness today.

We need leaders to demand attention to the lack of studies in bipolar disorder at a threshold that cannot be ignored by leaders of the NIMH. Patient advocacy groups must push the NIMH to fund treatment studies for bipolar disorder. It is clear that without some new form of pressure, the NIMH will fail in its stated mission to help make the lives of those with serious mental illness less grave. The current generation and many in the future generations of patients with bipolar disorder will otherwise face disaster.

Treating Symptoms of Bipolar Disorder in Children at Risk

April 10, 2020 · Posted in Current Treatments, Diagnosis · Comment 

At the 2019 meeting of the American Academy of Child and Adolescent Psychiatry, one symposium was devoted to new research on predicting onset of bipolar disorder in children who have a family history of the disorder. Below are some of the findings that were reported. See previous articles for more on this symposium.

Sub-Threshold Bipolar Disorder or BP-NOS is Impairing and Requires Treatment

In research Danella M. Hafeman’s research, children with BP-NOS were almost as ill as those with bipolar I disorder (BP I) and experienced equal incidence of suicide attempts, substance abuse, other simultaneous psychiatric diagnoses, and functional impairment, clearly indicating that they were in need of treatment. About 50–65% of participants with a family history of bipolar disorder converted from diagnoses of BP-NOS to BP I, while those with BP-NOS and no family history of bipolar disorder converted to BP I at rates of about 30–48%.

Several presenters presented data showing that those with sub-threshold bipolar disorder had severe functional impairment, a high incidence of suicide attempts, and additional diagnoses including ADHD, conduct disorder, anxiety, and substance abuse.

Diagnostic Tool Can Help Identify Children with Bipolar Disorder

Researcher Amy Yule indicated that a tool called the Child Behavior Checklist (CBCL) is effective for making the diagnosis of conduct disorder in children with bipolar disorder, while researcher Joseph Biederman showed that the CBCL can also identify children with bipolar I disorder and is faster and simpler to use in clinical practice than are full structured diagnostic interviews.
Researcher Janet Wozniak found that there was a high incidence of bipolar disorder in first-degree relatives of children with sub-threshold bipolar disorder, suggesting the validity of identifying youth with sub-threshold bipolar symptoms.

As discussed above, there is also a high incidence of children with BP-NOS progressing to a full diagnosis of bipolar I or II disorder (as many as 50% of those with a family history of bipolar disorder). However, the point is not to wait for the negative effects of a full diagnosis before beginning treatment: BP-NOS itself requires treatment.

Discussion and Emerging Consensus on Treatment, Particularly of BP-NOS

Experts in the field agree that family focused therapy (FFT) or its equivalent is a crucial first step to treatment of depression, cyclothymia (cycling between depressive and hypomanic symptoms that do not meet the threshold for a diagnosis of bipolar disorder), and BP-NOS in children who are at high risk of bipolar disorder because they have a parent with the disorder.

A second area of agreement is that young people with BP-NOS should have a positive therapeutic coach (which could be a treating physician if no other person is available), who can emphasize important early steps that can improve short- and long-term health. These include maintaining a healthy diet, exercise (such as participation in school sports), the practice of mindfulness and/or meditation, and playing and practicing a musical instrument. Parental support is also critical to decreasing negative expressed emotion.

Early interventions and wellness programs that focus on these factors are part of the successful Vermont Family Based Approach, led by psychiatrist Jim Hudziak, Director of the Vermont Center for Children, Youth, and Families. Since programs like these are not widely available, treating physicians must create their own teams to provide such encouragement, and teach families how to find or establish such a support network.

School teachers should be engaged in support of the treatment of a child with bipolar disorder. Teachers should pay special attention to behavioral symptoms of an ill child. It also may be important for physicians to connect directly with teachers to ensure that children recovering from an episode of bipolar disorder receive extra time for assignments, a decreased academic burden, and other support. Researcher Manon H. Hillegers indicated that intervention by a physician will likely be listened to and believed, while parental requests alone to teachers or to the school may go ignored.

Hillegers, like researcher Lakshmi Yatham and colleagues, have found that it takes a year after a first manic episode for a child’s cognition to return to normal, so that special allowances should be made for such students even many months after they have recovered from their mania.

Omega-3 Fatty Acids Improve Executive Function in Youth with Mood Disorders

January 29, 2018 · Posted in Current Treatments · Comment 

omega-3 fatty acids

A 2017 study by Anthony T. Vesco and colleagues in The Journal of Child Psychology and Psychiatry suggests that in youth with depression or bipolar not otherwise specified (BP-NOS), omega-3 fatty acid supplements improve executive functioning and behavior regulation compared to placebo.

Ninety-five participants aged 7–14 years received two capsules daily of either omega-3 fatty acids (1.87g total per day, mostly consisting of EPA) or placebo for 12 weeks. Those who received omega-3s showed improvement in executive functioning (which can include planning and decision-making), behavioral regulation, and metacognition, as rated by their parents.

Editor’s Note: Since omega-3 fatty acids have no known side effects, there is little reason not to try them in youth with depression or bipolar disorder.

BP-NOS Often Develops Into Bipolar I or II Disorder

November 4, 2011 · Posted in Course of Illness · Comment 

At a symposium on new research on juvenile bipolar disorder at the meeting of the American Academy of Child and Adolescent Psychiatry (AACAP) in 2010, David Axelson of the University of Pittsburgh summarized the longitudinal course of sub-syndromal bipolar disorder in children and adolescents as observed in a research program called COBY (Course and Outcome of Bipolar Youth). Axelson called attention to the 35% of the bipolar spectrum children who had a diagnosis of bipolar NOS (not otherwise specified) as opposed to the 58% who had full-blown bipolar I illness. BP-NOS is defined as illness not meeting criteria for bipolar I or II, including duration of illness and number of symptoms, so it includes presentations in which there is one fewer symptom present than the four required for a diagnosis of euphoric mania or the five required for a diagnosis of irritable mania. The mania or hypomania in BP-NOS must occur for at least four hours/day for at least four days.

young man

Overall, the COBY researchers found that among children with a BP-NOS diagnosis, it was the duration of the manic symptoms that tended to fall short of the requirements for a BP-I or BP-II diagnosis rather than any qualitative difference in clinical presentation. The COBY study followed 446 BP-NOS patients aged 7 to 17 for an average of five years using the LIFE methodology, which rates severity of ill states on a weekly basis. The assessments of LIFE data were conducted at an average of eight-month intervals.

Axelson’s key point was that within the 5-year period of the study, 45% of the children with BP-NOS, which some would consider a subthreshold bipolar disorder, converted to a full-blown bipolar disorder; 23% to a BP-I presentation and 22% to a BP-II presentation. If there was a positive family history of mania, it was even more likely that a child with BP-NOS would convert to BP-I or BP-II (58.5%, as opposed to 35.5% when there was no positive family history for mania).

Children with BP-NOS are almost as highly impaired as those with BP-I and BP-II illness, and clearly deserve early treatment intervention, both to alleviate problematic symptomatology, but also to possibly prevent the conversion to more full-blown BP-I and II syndromes. Axelson stressed the importance of treating those with BP-NOS who do not convert to BP I or II, because they too remain substantially impaired.

Treatment Guidelines for Two Hypothetical Cases in Children

There are no FDA-approved treatments for children under age 10 with bipolar disorder. For an article in Psychiatric Annals, this editor and Janet Wozniak asked experts how they would sequence treatment of a hypothetical case of a 6-year-old with extreme mood instability consistent with a diagnosis of BP -NOS (see Table I). We also asked how the experts would treat a different case of a 9-year-old with a full-blown psychotic BP-I mania (see Table II).

Table 1

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Table 2

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The results are presented  and discussed in detail in the article, and are presented here to reinforce several points. The recommendations for children under 10 and for BP NOS are highly similar to consensus guidelines for older BP I children compiled by Kowatch et al.

Treatments in the face of non-response to option A or others are sequenced differently by different experts, but almost always involve an atypical antipsychotic (AA) or a mood stabilizer (MS) such as lithium, valproate, carbamazepine/oxcarbazepine, or rarely, lamotrigine. Revisions of atypical antipsychotics and mood stabilizers and use of combinations are the common next strategies.