Parents’ History of Mood and Anxiety Disorders Increases Risk of These Disorders in Offspring
A 2016 article by researcher Petra J. Havinga and colleagues in the Journal of Clinical Psychiatry suggests that offspring of a parent with a mood or anxiety disorder are at higher risk for these disorders than offspring from non-ill parents. Havinga and colleagues studied 523 offspring of parents with one of these disorders. Among these offspring, 38.0% had had a mood or anxiety disorder by age 20, and 64.7% had had such a disorder by age 35. (Rates of these disorders in the general population are closer to 10%.)
The risk of offspring developing one of these disorders was even higher when both parents had a history of a mood or anxiety disorder, when a parent had an early onset of one of these illnesses, and when the offspring was female. The good news is that balanced family functioning had a protective effect, reducing the likelihood that the offspring would develop a mood or anxiety disorder.
Researcher David Axelson reported in a 2015 study published in the American Journal of Psychiatry that approximately 74% of the offspring of a parent with bipolar disorder went on to have a major psychiatric diagnosis over 6.7 years of followup. Similarly, researcher Myrna Weissman and colleagues reported in 2006 that the same high incidence of psychiatric diagnoses was true of the offspring of a parent with unipolar depression over 20 years of followup.
Editor’s Note: It is important to be vigilant for mood or behavioral disorders that may emerge in the offspring of a parent with a mood or anxiety disorder. Children at high risk should maintain a healthy diet and good sleep hygiene, exercise regularly, and perhaps try practicing mindfulness and meditation, as recommended by researcher Jim Hudziak. Family-focused therapy (developed by researcher David Miklowitz) can help when early symptoms appear in the offspring of a parent with bipolar disorder.
Another option is joining our Child Network, a secure online program that allows parents to track their children’s symptoms of anxiety, depression, attention-deficit hyperactivity disorder (ADHD), oppositional behavior, and mania. This may facilitate earlier recognition and treatment of dysfunctional symptoms, which can be treated with psychotherapy and medication.
SSRI Use During Pregnancy Linked to Adolescent Depression in Offspring
A 2016 article by Heli Malm and colleagues in the Journal of the American Academy of Child and Adolescent Psychiatry suggests that in utero exposure to selective serotonin reuptake inhibitor (SSRI) antidepressants may increase the risk of depression in adolescence. However, the study included potentially confounding factors. It is possible that women who took SSRIs during pregnancy had more severe depression than those who went unmedicated during pregnancy. The mothers in the study who took SSRIs also had more comorbid conditions such as substance abuse.
Editor’s Note: Women should balance the risks and benefits of antidepressant use during pregnancy, since depression itself can have adverse effects on both mother and fetus. It has recently been established that SSRI use during pregnancy does not cause birth defects, so women with depression that has not responded to non-pharmaceutical interventions such as psychotherapy, omega-3 fatty acid supplementation, exercise, mindfulness, and repeated transcranial magnetic stimulation (rTMS) may still want to consider SSRIs.
Family-Based Health Program Successful in Vermont
A statewide program to promote healthy behaviors within families has been successful in Vermont. The approach, described by researcher James J. Hudziak at the 2015 meeting of the American Academy of Child and Adolescent Psychiatry, is based on three assumptions. The first is that emotional and behavioral health is the cornerstone of all health. The second is that health behaviors are formed and sustained within families. The third is that promoting healthy behaviors, preventing illness, and intervening for better health outcomes are all important to enhancing the health of the population.
Vermont used community outreach (including town-hall public events), the media (including Twitter, blogs, radio, television, public service announcements, and a short film), and group trainings of community professionals to successfully spread health messages to families. The program targeted pediatricians’ offices, schools, community mental health centers, federally qualified health centers, and Departments of Health, Mental Health, and Child Welfare.
Hudziak has also suggested that programs of exercise, music, and mindfulness (all of which enhance brain growth and development) should be made universally available to children in school.
Exercise Improves Cognition and Normalizes Brain Activity
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.
Several Types of Psychotherapy Effective in Childhood Bipolar Disorder
Childhood onset bipolar disorder can be highly impairing. Treatment usually includes medication, but several types of psychotherapy have also been found to be superior to treatment as usual. These include family focused therapy, dialectical behavior therapy and multifamily psychoeducation groups, including Rainbow therapy.
Family focused therapy, developed by David Miklowitz, consists of psychoeducation about bipolar disorder and the importance of maintaining a stable medication routine. Families are taught to recognize early symptoms of manic and depressive episodes, and how to cope with them. Families also learn communication and problem solving skills that can prevent stressful interactions.
Dialectical behavior therapy was developed by Marsha Linehan, initially for the treatment of borderline personality disorder. It can be useful in bipolar disorder because participants learn how to manage stressors that might otherwise trigger depression or mania. DBT teaches five skills: mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness, and self management.
Multifamily psychoeducation was developed by Mary Fristad. In groups, children and parents learn about mood disorders, including how to manage symptoms, and also work on communication, problem solving, emotion regulation, and decreasing family tension.
Rainbow therapy is a type of multifamily approach also known as child and family-focused cognitive-behavioral therapy (CFF CBT). It integrates individual cognitive-behavioral therapy with family psychoeducation and mindfulness skills training. In a recent article in the journal Evidence Based Mental Health, Miklowitz reviewed the current research on Rainbow therapy. While the research to date has many limitations, he highlighted some benefits of Rainbow therapy: its flexibility, and its focus on treating parents’ symptoms along with children’s illness.
Psychotherapy of Childhood Bipolar Disorder
At the 2014 meeting of the American Academy of Child and Adolescent Psychiatry, there was an excellent symposium on different psychotherapeutic approaches for children and adolescents with bipolar disorder and related illnesses.
Amy West of the university of Illinois at Chicago started off this symposium by describing the effectiveness of child-and family-focused cognitive-behavior therapy or what is sometimes called RAINBOW therapy. Rainbow stands for Routine, Affect regulation, I can do it, No negative thinking, Be a good friend and balance life stressors, Oh how can we solve problems, and Ways to find support.
West emphasized the importance of routine in sleep, diet, medications, and homework, and indicated that frequent soothing is necessary. Posted reminders are also helpful.
Affect regulation can be encouraged by promoting coping skills, particularly around identifying what triggers mood swings and rage attacks and creating plans for dealing with them.
“I can do it” reminds parents and children to focus on strengths, successes, positive feedback, and the ability to call for help.
“No negative thinking” encourages positive restructuring and reframing of negative perspectives. Part of this includes mindfulness training for children and parents, who are taught to focus on breathing and accepting thoughts and emotions.
Being a good friend focuses on listening, engaging friends, and enhancing communication.
“Oh how can we solve problems” reminds families to have an attitude of problem solving.
Remembering ways to find support reminds parents to connect with relevant resources, and also coaches parents to be advocates for their children.
In a randomized study of 12 sessions of child and family focused cognitive behavior therapy, the children did much better than those receiving treatment as usual and showed greater improvement in mania and depression as well as overall functioning.
The second presentation was given by Mary Fristad of Ohio State University. She treated children with bipolar disorder not otherwise specified (BP-NOS) with psychotherapy and omega-3 fatty acids. Some research had suggested the efficacy of omega-3 fatty acids in childhood mood disorders and a much larger literature was positive in adult mood disorders. Given the safety of the manipulation, she felt it was worth trying in young children and those with BP-NOS who are rarely studied formally. She also cited a 2010 study by Amminger et al. in children who were at ultra high risk for schizophrenia. In that study, patients were randomized to 12 weeks of omega-3 fatty acids or placebo, and omega-3 fatty acids were associated with a very low conversion rate to full-blown psychosis, 4.9%, compared to 27.5% for those receiving placebo. Fristad’s psychotherapy also emphasized education, support, and skill building in order to enhance understanding of the illness and its treatment. This would help ensure better compliance and better treatment outcome. Her formal treatment manual is available at www.moodychildtherapy.com.
Fristad randomized children with bipolar not otherwise specified, average age 10.2 +/- 0.2 years to either her psychotherapy plus omega-3 fatty acids or therapy plus placebo. Therapy plus omega-3 was much more effective on most outcome measures.
Editor’s Note: Given the safety of omega-3 fatty acids, even these limited data would appear to justify their use in children with BP-NOS in the context of psychotherapy and psychoeducation.
The third presenter was David Miklowitz of UCLA who discussed family focused therapy. This approach has proven effective in studies of both adults and adolescents with bipolar disorder, and as well for those with prodromal symptoms. Read more
A Symposium on High Risk Studies: Offspring of Parents with Bipolar Disorder
In a symposium at the 2014 meeting of the International College of Neuropsychopharmacology, four researchers shared insights on children who are at higher risk for bipolar disorder because they have a parent with the disorder.
Researcher John Nurnberger has been studying 350 children of parents with bipolar disorder in the US and 141 control children of parents with no major psychiatric disorder, following the participants into adolescence. He found a major affective disorder in 23.4% of the children with parents who have bipolar disorder and 4.4% of the controls. Of the at-risk children, 8.5% had a bipolar diagnosis versus 0% of the controls.
Nurnberger found that disruptive behavior disorders preceded the onset of mood disorders, as did anxiety disorders. These diagnoses predicted the later onset of bipolar disorder in the at-risk children, but not in the controls. A mood disorder in early adolescence predicted a substance abuse disorder later in adolescence among those at risk.
In genome-wide association studies, the genes CACNA1C and ODZ4 are consistently associated with risk of bipolar disorder, but with a very small effect size. Therefore, Nurnberger used 33 different gene variants to generate a total risk score and found that this measure was modestly effective in identifying relative risk of developing bipolar disorder. He hopes that using this improved risk calculation along with family history and clinical variables will allow better prediction of the risk of bipolar onset in the near future.
Researcher Ann Duffy reported on her Canadian studies of children who have a parent with bipolar disorder and thus are at high risk for developing the disorder. In contrast to the studies of Nurnberger et al. and many others in American patients, she found almost no childhood onset of bipolar disorder before late adolescence or early adulthood. She found that anxiety disorders emerge first, followed by depression, and then only much later bipolar disorder. Bipolar disorder occurred with comorbid substance abuse disorders in only about 10-20% of cases in 1975, but substance abuse increased to 50% of bipolar cases in 2005. The incidence of comorbid substance disorder and the year at observation correlated strongly, indicating a trend toward increased substance abuse over the 30-year period.
Duffy found that having parents who were ill as opposed to recovered was associated with a more rapid onset of mood disorder in the offspring, usually in early adulthood. Duffy emphasized the need to intervene earlier in children of parents with bipolar disorder, but this is rarely done in clinical practice. Read more
Memory Tips for Bipolar Disorder
Like cancer patients undergoing chemotherapy, patients with bipolar disorder often have memory problems, particularly if they have had many prior episodes. Some memory tips from CancerCare’s Chemobrain Information Series may also help patients with bipolar disorder remember things better and keep their memory sharp. Here are some of their tips:
Make lists. Carry a notepad with you, or use a smartphone to keep track of errands, shopping lists, daily tasks, and when you should take your medications.
Use a paper or electronic day planner or a personal organizer to keep track of appointments and special days like birthdays or anniversaries.
Use a wall calendar and hang it in a place that you will see it multiple times per day.
Carry a notebook and record everything you need to remember, including to-do lists; the dates, times, and addresses of appointments; important telephone numbers; and the names of people you meet and a brief description of them. You can also use the notebook to keep track of medical information: your medication schedule, any symptoms or side effects you are having, or questions to ask your doctor. You can also do this using an app like What’s My M3 or by downloading a personal mood charting calendar from our website.
Leave yourself a voicemail message to remember something important. When you listen to it later, write down the information.
Organize your home or office. Keep things in familiar places so you always know where to find them.
Avoid distractions. Find a quiet, uncluttered place to work or think where you can focus your attention for longer.
Have conversations in quiet places. This will help you concentrate better on what the other person is saying.
Repeat information aloud, and write down important points. If someone gives you information about an appointment, you might repeat the time, date, and location of the appointment out loud while righting it down.
Keep your mind active. You can use crossword puzzles, word or math games, or attend events about topics that interest you.
When writing, proofread. Double-check whether you’ve used the correct words and spellings.
Train yourself to focus through mindfulness. For example, if you keep misplacing your keys, pay extra attention each time you set down your keys. You may say aloud, “I’m putting my keys down on the counter.” Hearing the auditory cue can boost your memory.
Exercise, eat well, and get plenty of rest and sleep. These habits will help your memory work best.
Tell your loved ones that you are having memory problems, so that they’ll understand that you may forget things you may normally be able to remember. They can help you or encourage you.
Psychotherapy Prevents Recurrence of Depression
New research shows that psychotherapy lowers the risk of relapse in unipolar major depression more than “treatment as usual” does, and also heads off depression in children at high risk.
At the 2013 meeting of the American Psychiatric Association, researcher Pim Cuijpers reviewed 32 trials of cognitive behavior therapy, intensive behavioral therapy, and problem solving therapy used for the prevention of depression and found that these therapies were associated with a 21% lower risk of relapse compared to treatment as usual.
There were five critical elements that made these therapies useful: they supported coping with depression, and they included exercise, mindfulness, internet-based cognitive behavior therapy, and problem solving.
Among those who presented at the meeting, Greg Clarke of Kaiser Permanente, Oregon discussed an 8-week course on coping with stress given to a group of adolescents (aged 14 to 16) who had four times the normal risk of developing depression because each had a parent with depression. Clarke found a significant reduction in depression among the adolescents who received therapy compared to controls.
Insomnia can be a precursor to a first depression or to recurrent depression. Cognitive behavior therapy was more effective in improving sleep than a comparative sleep hygiene course.
Researcher Judy Garber presented data showing that cognitive behavior therapy was effective in 13- to 17-year-olds who had a parent with depression and had themselves had a prior depression or were currently sub-syndromal. The effect of the therapy was only significant if the parent was not depressed at intake.
Meditation Improves Depression and Stress in Adolescents
A recent study in the UK compared students whose schools instituted the 9-week international Mindfulness in Schools Program (MiSP) curriculum to those who were taught a standard curriculum. Students at schools with MiSP were taught techniques for sustaining attention aimed at changing their thoughts, actions, and feelings.
Students who participated in MiSP training had fewer depressive symptoms immediately after the training and three months later. They also reported lower stress and greater well-being at follow-up. Those students using the techniques they learned in the program more consistently had better scores for depression, stress, and well-being than their peers who used the techniques less often. The study by Kuyken et al., which was published in the British Journal of Psychiatry in 2013, included 522 students between the ages of 12 and 16.
Psychological well-being has been linked to better learning and performance in school, in addition to better social relationships. Researchers suggested that because this kind of mindfulness training is designed to help students deal with everyday stressors and experiences, it has benefits for all students, regardless of their level of well-being.
