A Calculator of Risk for Bipolar Disorder in Youth

January 3, 2018 · Posted in Risk Factors · Comment 

Daniella Hafeman of the University of Pittsburgh described a risk calculator for predicting an individual’s risk for bipolar disorder, which is available at www.pediatricbipolar.pitt.edu. Possible factors included in the risk calculation include a parent’s early age of onset of bipolar disorder, mood shifts early in life, a child’s anxiety or depression symptoms, later affective mood shifts, and new onset of subthreshold mania.

Editor’s Note: A “poor man’s” assessment of risk can also be of help to a family or clinician. There are four components. The first is genetic. Having one parent with bipolar disorder is a potent risk factor, and can be further magnified if the other parent also has a mood disorder. If three or more first degree relatives or three or more generations of first degree relatives have a mood disorder, this further increases risk four- to six-fold.

Perinatal vulnerability is another factor. Beyond these genetic vulnerabilities, a history of maternal toxoplasmosis or a viral infection during pregnancy, or the infant being noticeably underweight at birth can contribute to bipolar risk.

Childhood adversity also contributes to vulnerability to early onset of bipolar illness. A history of psychosocial stress in the child’s early years, such as abuse or abandonment, can be an added risk factor.

Prodromal or preliminary symptoms are also a risk factor. The development of an anxiety or depressive disorder, a disruptive behavioral disorder, or a bipolar not-otherwise-specified diagnosis (BP-NOS, used to describe manic symptoms of short duration) further increases risk. In studies by David Axelson and Boris Birmaher, 50% of children with an initial diagnosis of BP-NOS developed full-blown bipolar I or II illness upon several years of followup if there was a family history of bipolar disorder. About one-third converted to full bipolar disorder if there was no family history of bipolar disorder.

Thus, if a child has three or all four types of risk factors, their risk would be substantial. In this case, one might consider attempts at prevention. This could include a good diet rich in omega-3 fatty acids, regular exercise, joining a school sports team, developing good sleep habits, playing a musical instrument, and engaging in something akin to family focused therapy. Family focused therapy emphasizes psychoeducation, good communication skills, and problem solving. Attending to and treating parents’ symptoms and building a support system for both parents and the child can also help.

While these endeavors are not a guarantee to prevent the onset of more severe illness, they are all health-promoting in general and have few downsides.

Offspring of Bipolar Parents Have More Psychiatric Illness

September 22, 2017 · Posted in Risk Factors · Comment 

family with boyA 2017 study from the Czech Republic found that children and adolescents with at least one parent with bipolar disorder had much higher lifetime rates of mood and anxiety disorders than their peers who did not have a parent with bipolar disorder. The offspring of bipolar parents also had lower quality of life, less social support, poorer self-perception, poorer relationships with their peers and parents, and more difficult home lives than those whose parents did not have bipolar disorder.

The study by Michal Goetz and colleagues in the Journal of Child and Adolescent Psychopharmacology reported that 86% of the children of bipolar parents would be diagnosed with a psychiatric disorder in their lifetime. Similarly, David Axelson and colleagues from the Pittsburgh Bipolar Offspring Study reported in the American Journal of Psychiatry in 2015 that 74.2% of children with a parent with bipolar disorder would receive a lifetime psychiatric diagnosis, and a 2006 study by Myrna M. Weissman in the American Journal of Psychiatry found that the offspring of a unipolar depressed parent were three times more likely to have a psychiatric illness than offspring of nondepressed parents over 20 years of follow-up. Another study by this editor (Robert M. Post) and colleagues in the Bipolar Collaborative Network published in the Journal of Affective Disorders in 2016 found that a third of children at high risk due to a parent’s bipolar diagnosis would go on to have a psychiatric illness.

The Goetz study included a total of 86 participants between the ages of 7 and 18. Half had a parent with bipolar disorder and half did not. One limitation of the study was its recruitment procedure. Parents with bipolar disorder who enrolled their children in the study may have done so out of concern for their offspring’s mental health, increasing illness rates in the group with bipolar parents. Researchers were also aware of parents’ diagnoses, which may have affected their ratings of the young people’s symptoms. Despite these limitations, the study and its predecessors still suggest that psychiatric illness in a parent puts children at very high risk for a psychiatric illness themselves and can affect their wellbeing in a variety of ways.

Goetz and colleagues suggest that there is a need for proactive and complex care of families with psychiatric illness. They suggest that good communication is needed between adult and youth psychiatric services, with physicians who treat adults with bipolar disorder inquiring about those patients’ children and referring them to specialized psychiatric services for youth.

Editor’s Note: I not only endorse the conclusions of Goetz and colleagues, but would further recommend that parents with a diagnosis of bipolar disorder or unipolar depression discuss their children’s mood and behavior with their own psychiatrists and the children’s primary care physicians.

Parents of children aged 2 to 12 may enroll in our own Child Network, a secure online portal where they can record weekly ratings of their children’s symptoms and share these with their physicians.

There are many effective psychotherapeutic interventions for children with anxiety and mood disorders that should be sought for a child with symptoms that impair his or her functioning. Two evidence-based treatments are Family Focused Therapy, which incorporates family members into treatment so that they better understand the illness and can be supportive of the affected child, and cognitive behavioral therapy, in which negative patterns of thoughts and behaviors are challenged and patients are taught more effective problem-solving skills. When childhood psychiatric illness is recognized and treated appropriately, the results are often excellent, and it is possible that heading off the illness early may even prevent the development of more severe illness later in the child’s life.

Amygdala Hyperactivity Linked to Family History of Depression

December 9, 2016 · Posted in Risk Factors · Comment 

family history of depression

In new research presented at the 2016 meeting of the Society of Biological Psychiatry, researcher Tracy Barbour and colleagues revealed that youth with a family history of depression showed more amygdala activation in response to a threat than people without a family history of depression. This amygdala hyperactivity was linked to low resilience to stress and predicted worsening depressive symptoms over the following year.

In the study, 72 non-depressed youth were shown images of cars or human faces or cars that seemed to loom in a threatening way. Brain scans showed increased amygdala activity in participants with a family history of depression compared to those without such a history.

The amygdala is an almond-shaped part of the brain in the temporal lobe that has been linked to emotional reactions and memory, decision-making, and anxiety.

In Rats, Dad’s Cocaine Use Affects Son’s Spatial Memory

July 14, 2016 · Posted in Genetics, Neurobiology · Comment 

cocaine use affects offspring's spatial memory

Evidence is mounting that certain behaviors by parents can leave marks on their sperm or eggs that are passed on to their offspring in a process called epigenetics. In a recent study by researcher Mathieu Wimmer and colleagues, male rats that were exposed to cocaine for 60 days (the time it takes for sperm to develop fully) had male offspring who showed diminished short- and long-term spatial memory compared to the offspring of male rats that were not exposed to cocaine. Female offspring were not affected in this way.

The spatial tasks the offspring rats completed depended heavily on the hippocampus. Wimmer and colleagues believe that cocaine use in the fathers decreased the amount of a brain chemical called d-serine in the offspring. D-serine plays a role in memory formation and the brain’s ability to form synaptic connections. Injecting the offspring of rats who were exposed to cocaine with d-serine before the spatial memory tasks normalized the rats’ performance.

Mindfulness Therapy Improves Anxiety in Youth with a Bipolar Parent

July 6, 2016 · Posted in Current Treatments · Comment 

mindfulness therapy

Children of parents with bipolar disorder are prone to anxiety and emotional dysregulation, but treating these symptoms with antidepressants can provoke symptoms of mania. Thus, non-pharmacological treatements for anxiety and depression are needed. A recent study by Melissa DelBello found that twelve weeks of mindfulness-based cognitive therapy improved symptoms of anxiety and mood dysregulation in 20 youth with a bipolar parent. DelBello used functional magnetic resonance imaging (fMRI) to observe that the therapy increased activation of brain structures related to emotion and sensing. Amygdala activation differed between those with anxiety and those with mood dysregulation, suggesting that the therapy’s effect was on regions that modulate the amygdala, including prefrontal and insular regions, rather than on the amygdala itself.

Anxiety, Depression, Unstable Mood, and Low-Level Mania Best Predictors of Bipolar Disorder

May 4, 2016 · Posted in Diagnosis, Risk Factors · Comment 

kids at high risk for bipolar disorder

Researchers are looking for better ways of predicting whether children at risk for bipolar disorder will go on to develop the illness. A 2015 study by David Axelson and colleagues in the American Journal of Psychiatry reported that in the offspring of parents with bipolar disorder, diagnoses of sub-threshold mania, depression, and disruptive behavior disorders were associated with subsequent diagnosis of full-blown Bipolar I or Bipolar II disorders six to seven years later.

More recently, in an article by Danella M. Hafeman and colleagues in the American Journal of Psychiatry, the same group of investigators has examined how symptoms (rather than categorical diagnoses, as in the earlier study) predict the development of bipolar disorder. In children and adolescents at high risk for bipolar disorder (because they have a parent with the disorder) three types of symptoms were the best predictors of later bipolar disorder: anxiety/depression at the time participants entered the study, unstable mood or irritability both when entering the study and shortly before a bipolar diagnosis, and low-level manic symptoms observed shortly before diagnosis.

The earlier the age at which a parent was diagnosed with a mood disorder, the greater the risk that the offspring would also be diagnosed with bipolar disorder. Youth with all four risk factors (anxiety or depression, mood changes, low-level mania, and a parent who was diagnosed with a mood disorder at an early age) had a 49 percent chance of developing bipolar disorder, compared to a 2 percent chance among those without those risk factors.

Childhood onset of bipolar disorder and long delays until first treatment for depression or mania are both significant predictors of a poor outcome in adulthood compared to adult onsets and shorter delays to treatment. Read more

Exercise Improves Cognition and Normalizes Brain Activity

February 12, 2016 · Posted in Potential Treatments · Comment 

exercise improves cognition

Exercise isn’t just good for the body—new research suggests it can improve cognition and normalize brain activity.

At the 2015 meeting of the American Academy of Child and Adolescent Psychiatry, researcher Benjamin I. Goldstein reported that 20 minutes of vigorous exercise on a bike improved cognition and decreased hyperactivity in the medial prefrontal cortex in adolescents with and without bipolar disorder.

At the same meeting, researcher Danella M. Hafeman reported that offspring of parents with bipolar disorder who exercised more had lower levels of anxiety.

A plenary address by James J. Hudziak also suggested that exercise, practicing music, and mindfulness training all lead to improvements in brain function and should be an integral part of treatment for children at high risk for bipolar disorder and could be beneficial for all children.

Editor’s Note: Recognizing and responding to mood symptoms is key to the prevention and treatment of bipolar disorder in children and adolescents at high risk for the illness. For these young people, exercise, a nutritious diet, good sleep habits, and family psychoeducation about bipolar disorder symptoms may be a good place to start. Joining our Child Network may also be helpful.

Children at Risk for Bipolar Disorder May Have Adverse Reactions to Antidepressants

February 11, 2016 · Posted in Current Treatments · Comment 

adverse reaction to antidepressantsAt the 2015 meeting of the American Academy of Child and Adolescent Psychiatry, researcher Jeffrey R. Strawn reported that among children at high risk for bipolar disorder (because of a family history of the disorder) who are prescribed antidepressants for depression and anxiety, adverse reactions are common. These reactions include irritability, aggression, impulsivity, and hyperactivity, and often lead to discontinuation of the antidepressant treatment.

Younger patients at risk for bipolar disorder were more likely to have an adverse reaction to antidepressants. Risk of an adverse reaction decreased 27% with each year of age.

Offspring of Bipolar Parents at High Risk for Psychiatric Disorders

February 10, 2016 · Posted in Risk Factors · Comment 

children of parents with bipolar disorder are at high risk for the illness

Researcher Juan David Palacio reported at the 2015 meeting of the American Academy of Child and Adolescent Psychiatry that compared to offspring of non-ill parents, children of parents with bipolar I disorder are at high risk for psychiatric disorders, particularly bipolar spectrum disorders and substance use disorders. They were also at risk for symptoms of anxiety disorders and conduct disorder. Palacio’s findings from Colombia mirror those from other studies of familial risk and suggest the importance of vigilance to detect these disorders early and provide appropriate treatment. Our Child Network may help.

Facial Emotion Recognition Deficient in Bipolar Disorder

February 1, 2016 · Posted in Peer-Reviewed Published Data · Comment 

facial expressionsemotions

In the past decade, several studies have indicated that people with bipolar disorder have less ability to recognize the emotions expressed on people’s faces than do healthy controls. A 2013 meta-analysis by Cecilia Samamé and colleagues concluded that facial emotion recognition was deficient in people with bipolar disorder regardless of their current state. A 2011 quantitative review article by Christian G. Kohler and colleagues revealed that this difficulty distinguishing emotions is general, rather than specific to any one emotion.

A 2015 study by Esther Vierck and colleagues in the journal Psychiatry Research showed that both euthymic patients with bipolar disorder and their first-degree relatives without bipolar disorder performed worse on tests of emotion recognition than did normal controls. The findings in healthy relatives suggest that the deficit may be a familial risk factor for the development of bipolar disorder.

These deficits in facial emotion recognition have also been seen in 4 out of 5 studies of children with early-onset bipolar disorder, including those who are euthymic. 2008 studies by Melissa A. Brotman and colleagues showed that even children just at high risk for bipolar disorder due to a family history of the disorder had deficient emotion recognition.

This literature indicates that deficiencies in facial emotion recognition consistently accompany bipolar disorder and may also be a sign that a child or teenager is at risk for bipolar disorder. Since these deficits can create social and interpersonal difficulties, it may be useful to teach better emotion recognition skills to people with bipolar disorder or those at high risk for the illness.

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