Preventing Illness in the Offspring of a Parent with Bipolar Disorder

April 18, 2019 · Posted in Potential Treatments 

family with boy

A 2018 article by researcher Robert Freedman and colleagues in the American Journal of Psychiatry reported that prenatal nutritional supplements can reduce mental illness in at-risk offspring. The article made a good case for supplementation with folate, phosphatidylcholine, and vitamins A and D.

Here we describe some additional ways to minimize risk of mental illness in children who are at risk for bipolar disorder or other mental illnesses.

Some efforts at prevention can begin even before a child is conceived. Avoiding smoking or drinking alcohol and maintaining a nutritious diet to prevent inflammation and excessive weight gain before conception could reduce adverse epigenetic effects on the offspring. Epigenetics refers to environmental influences on gene transcription. The impact of life experiences such as a mother or father’s substance use is not registered in their child’s DNA sequence, but can influence the structure of the child’s DNA or its packaging.
Maternal good health and wellbeing during pregnancy has also been shown to improve neonatal health and functioning.

Once a child is born, they can be encouraged in healthy habits, including a nutritious diet, good sleeping habits, regular vigorous exercise, and mindfulness/meditation training (which pediatric psychiatrist James Hudziak has suggested should be universal).

For a child who is beginning to develop mood or behavioral symptoms, more intensive intervention may be prudent. Research supports the effectiveness of family interventions such as family-focused therapy (FFT) for youth with depression, cyclothymia, or bipolar disorder not otherwise specified (BP-NOS) and a family history of bipolar disorder. Researcher David J. Miklowitz described the effects of this intervention in a 2013 article in the Journal of the American Academy of Child and Adolescent Psychiatry.

Depression in children 3 to 6 years of age is as common as depression in older children (with rates around 1–2%), and robust improvements have been observed when families engage in parent child interaction therapy (PCIT) with a focus on emotional development. In PCIT, parents are coached while interacting with their children and encouraged to establish warm interactions while setting appropriate limits. In a study by Joan L. Luby and colleagues published in the American Journal of Psychiatry in 2018, using PCIT modified to include an emotional development component improved depression and associated symptoms in children aged 3 to 11, and it also improved mothers’ mood and behavior.

Data on nutritional supplements for children as an active intervention for early psychiatric symptoms are less well delineated, but deserve consideration. Many ill children have low vitamin D or an outright deficiency, and one study found that vitamin D supplementation improved behavior. The antioxidant N-acetylcysteine (NAC) improves depression and anxiety in adults and irritability in children with autism (at 2,700mg/day). It is also effective in a variety of habit-related and substance abuse disorders. Dosing for a child at risk for psychiatric illness might begin with 500mg/day and increase 500mg/week to a maximum of about 2,500–3000mg/day.

For children who face some trauma or adversity such as abuse or neglect, acetyl-L-carnitine (ACL) might be considered. ACL is low in depressed adults who had an early onset of their depression and in those with a history of abuse in childhood. There is evidence that ACL improves depression in adults. In animal models of depression, ACL works faster than antidepressants and has an epigenetic mechanism that rapidly normalizes low levels of the metabotrophic glutamate receptor mGluR-2, which decrease with stress, allowing too much release of the neurotransmitter glutamate.

For children with bipolar not otherwise specified (BP-NOS), more traditional medications might be contemplated in addition to family-focused therapy. High on the list would be the antipsychotic lurasidone, which is now approved by the US Food and Drug Administration for bipolar depression in 10- to 17-year-olds. Anticonvulsants such as lamotrigine or oxcarbazepine (and valproate in boys only) might also be considered, as well as lithium.

Lithium should be given strong consideration if there is a family history of bipolar disorder, and especially if there is a family history of responsiveness to lithium. BP-NOS can be difficult to stabilize, and 35-50% of those diagnosed with it convert to a diagnosis of bipolar I or II after several years of follow up, especially if there is a family history of bipolar disorder.
Ideally, treating risk factors and/or early symptoms of psychiatric illness would prevent the development of full-blown illness. Efforts at prevention might be most important in a child with a parent who had an early onset of bipolar disorder, as this is an additional risk factor for early-onset illness in the child. Further risk factors for early-onset illness are: 1) a loaded family history in parents and grandparents, not only of bipolar disorder but also of depression, suicide attempts, alcohol abuse or substance abuse, and 2) experiencing verbal, physical, or sexual abuse in childhood. Another risk factor is the family living in the US (as opposed to Europe), where a quarter of those who develop bipolar disorder do so prior to age 13, and two-thirds prior to age 18.

The data are striking that early comprehensive intervention after a first or second manic episode in adolescents or adults reduces episode recurrences compared to treatment as usual. Comprehensive intervention includes psychotherapy, psycho-education, mood charting, and pharmacotherapy. The randomized intervention described by researcher Lars V. Kessing and colleagues in a 2013 article in the British Journal of Psychiatry lasted two years, but the benefits continued over the subsequent four years, indicating that early intervention could greatly improve the trajectory of the illness over a period of six years.

Stopping the transgenerational transmission of psychiatric illness with comprehensive therapeutic intervention might be taken on as a goal for each family with children at high risk, even if data for the effectiveness of prevention strategies are not ironclad. This would meet an accepted standard for evidence-based medicine: when direct gold-standard evidence is lacking, physicians and families need to go with the next-best data available, especially when treatment options are safe and the likely outcomes of untreated illness are serious or even disastrous.

Until early intervention studies in children with early signs of psychiatric illness or those who are at high risk for psychiatric illness prove otherwise, families and physicians would be justified in presuming that the robust data from Kessing’s study would also apply to these younger patients. Early intervention studies in young people with schizophrenia have been conducted over the past two decades, and it is too bad that there have been few efforts to conduct these for bipolar and related disorders. Parents whose own bipolar illness started early and/or was compounded by other psychiatric illnesses could thus reasonably consider intervening early in their child in an effort to minimize the risk of later serious psychiatric illness.


Comments are closed.