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Untreated early-onset bipolar disorder is associated with higher rates of rapid cycling, more comorbidity, and more severe mania and depression than adult-onset bipolar disorder. Correctly diagnosing bipolar disorder early in its course can prevent exposing a young patient to treatments that may exacerbate or advance the progression of the disorder. Appropriate pharmacologic and psychosocial interventions are necessary in the acute treatment of pediatric bipolar disorder.
Bipolar disorder is an increasingly common diagnosis given to children and adolescents. Most studies of lithium, anticonvulsants, and atypical antipsychotics have been conducted in adult populations, but new data are providing information on the safety and tolerability of these medications for treating children and adolescents. Although generally well tolerated, psychotropic agents have different side effect profiles that should be considered when planning treatment regimens for pediatric patients. Additional controlled and comparative trials are needed on the safety and tolerability of these medications in young patients, especially for long-term maintenance treatment.
Pediatric-onset bipolar disorder is common but often difficult to diagnose in younger patients. Clinicians should be sure to establish the presence of a full manic episode to make the diagnosis of bipolar I disorder. Because adult criteria are used for children and adolescents, clinicians also should be aware of developmental norms that can help to make an accurate diagnosis. Bipolar disorder NOS and other disorders in children and adolescents may be prodromal states for bipolar disorder, especially in the presence of a positive family history.
Objective: To study the relationship between negative life events and demographic and clinical variables in youth with bipolar I disorder, bipolar II disorder, and bipolar disorder not otherwise specified (NOS), as well as to compare the rates of life events in youth with bipolar disorder, depressive and/or anxiety disorders (DEP-ANX), and healthy controls.
Method: Subjects included 446 youth, aged 7 to 17 years, meeting DSM-IV criteria for bipolar I, bipolar II, or an operationalized definition of bipolar disorder NOS, and were enrolled in the Course and Outcome of Bipolar Illness in Youth study. Subjects completed the Life Events Checklist. Sixty-five DEP-ANX and 65 healthy youth were obtained from previous studies using similar methodology. The study was conducted from October 2000 to July 2006.
Results: Older age, lower socioeconomic status, living with nonintact family, non-Caucasian race, anxiety, and disruptive disorders were associated with greater number of total negative life events. Specifically, increased independent, dependent, and uncertain negative life events were associated with lower socioeconomic status, nonintact family, and comorbid disruptive disorders. Increased independent negative life events were additionally associated with non-Caucasian race and comorbid anxiety disorders. Increased dependent and uncertain negative life events were also associated with older age. DEP-ANX youth reported a similar rate of negative life events as bipolar youth, and both groups had more negative life events than the healthy controls. Bipolar youth reported fewer total and dependent positive life events compared to DEP-ANX and healthy youths.
Conclusions: Similar to DEP-ANX youth, bipolar youth are exposed to excessive negative independent and dependent life events, which may have implications in the long-term outcome and negative consequences associated with this disorder.
Submitted: December 12, 2008; accepted April 24, 2009.
Corresponding author: Soledad Romero, MD, Hospital Clinic University of Barcelona, Institute Clinic of Neuroscience, Villarroel 170, Barcelona, Catalonia 08036, Spain ([email protected]).
From our regular book review column.
Clinical Manual of Child and Adolescent PsychopharmacologyClinical Manual of Child and Adolescent Psychopharmacology
Bipolar disorder is an increasingly common diagnosis in children and adolescents. Although psychosocial interventions are important for these young patients, treatment guidelines presently focus on pharmacologic therapy in the acute treatment of pediatric bipolar I disorder. Placebo-controlled studies have been conducted with lithium, anticonvulsants, and atypical antipsychotics, but more research is needed, especially in areas other than acute manic and mixed episodes. Additional studies are needed to determine the safest and most effective agents for treating children and adolescents with bipolar disorder.
Objective: This study examines the number and type of medical comorbidities among youth diagnosed with bipolar disorder.
Method: This is a retrospective data analysis using the 2000-2001 Thomson Medstat MarketScan medical claims and administrative files. The population included a national sample of youth (ages 6-18 years) from privately insured families within the United States. Number of chronic medical conditions and type of medical comorbidity were analyzed in ICD-10-diagnosed youth with bipolar disorder (N = 832) and other types of psychiatric disorders (N = 21,493) using The Johns Hopkins Adjusted Clinical Groups Case Mix System, Version 8.0.
Results: Thirty-six percent of youth with bipolar disorder had 2 or more chronic health conditions versus 8% of youth with other psychiatric diagnoses. The following categories of medical conditions were significantly more prevalent in youth diagnosed with bipolar disorder: cardiology, gastrointestinal/hepatic, neurologic, musculoskeletal, female reproductive, and respiratory. Toxic effects and adverse events were also higher in youth with bipolar disorder, compared to youth with other psychiatric disorders.
Conclusions: Youth with bipolar disorder experience higher rates of several medical illnesses compared to youth with other psychiatric diagnoses. Several factors may explain this phenomenon, including worse medication side effects, unhealthy lifestyle behaviors, poorer access to health care services, socioeconomic status, and biologic susceptibility. Moreover, a diagnosis of bipolar disorder may reflect more frequent health care utilization and therefore more opportunities for additional medical diagnoses. Further understanding regarding reasons for these relatively high rates of comorbidity among youth diagnosed with bipolar disorder may be helpful in improving overall health and quality of life during the early stages/onset of this disorder.
Submitted: October 25, 2008; accepted March 10, 2009.
Online ahead of print: September 8, 2009.
Corresponding author: Sara E. Evans-Lacko, PhD, Health Services Research Department, Institute of Psychiatry, King's College London, De Crespigny Park, London SE5 8AF, United Kingdom ([email protected]).
Objective: To determine whether the symptom presentation of major depressive disorder (MDD) in a large clinical sample of youngsters is influenced by age, sex, and the interaction of age and sex.
Method: The sample included 559 children (mean age' ‰=' ‰11.69 years; range, 7-14 years; 247 girls) with MDD recruited from 23 mental health facilities across Hungary. Psychiatric evaluations were conducted via the semistructured Interview Schedule for Children and Adolescents-Diagnostic Version (ISCA-D). Final DSM-IV diagnoses were rendered via the best-estimate diagnostic procedure. Evaluations were conducted between April 2000 and May 2005.
Results: Six depression symptoms increased with age: depressed mood (odds ratio [OR]' ‰=' ‰1.10, P' ‰<' ‰.05), hypersomnia (OR' ‰=' ‰1.17, P' ‰<' ‰.05), psychomotor retardation (OR' ‰=' ‰1.11 P' ‰<' ‰.05), fatigue (OR' ‰=' ‰1.13, P' ‰<' ‰.01), thoughts of death (OR' ‰=' ‰1.11, P' ‰<' ‰.05), and suicidal ideation (OR' ‰=' ‰1.18, P' ‰<' ‰.01), while psychomotor agitation decreased with age (OR' ‰=' ‰0.91, P' ‰<' ‰.05). Boys were less likely to evidence anhedonia (OR' ‰=' ‰0.67, P' ‰<' ‰.05), insomnia (OR' ‰=' ‰0.68, P' ‰<' ‰.05), and hypersomnia (OR' ‰=' ‰0.56, P' ‰<' ‰.05) but more likely to have psychomotor agitation (OR' ‰=' ‰1.59, P' ‰<' ‰.01). There were no age-by-sex interactions. Rates of somatic complaints did not decrease with age (OR' ‰=' ‰1.01, P' ‰>' ‰.05).
Conclusions: The symptom presentation of MDD becomes somewhat more neurovegetative as children get older. However, girls display more affective and atypical symptoms across all age groups. Somatic complaints were common regardless of age and should be considered an associated feature of depression in children and adolescents.
Submitted: December 2, 2008; accepted February 23, 2009.
Online ahead of print: August 25, 2009.
Corresponding author: Nestor L. Lopez-Duran, PhD, University of Michigan, Department of Psychology, 530 Church St, 2253 East Hall, Ann Arbor, MI 48109 ([email protected]).
Objective: To identify subgroups of severely psychiatrically impaired children on the basis of the complexity of their histories of exposure to abuse and other potential traumatic stressors, and to examine the relationship of complex trauma histories to DSM-IV-TR psychiatric diagnoses.
Method: In a sample of 397 consecutive inpatient child psychiatry admissions, cluster analysis was used to identify subgroups on the basis of measures of documented physical or sexual abuse, parental impairment (arrest, violence, and/or substance use), and disrupted attachment (ie, out-of-home placement). Data were collected for the years 1992 through 2002.
Results: Four subgroups were identified. Two "low trauma" subgroups had infrequent histories of abuse and out-of-home placement but were distinguished by low/moderate versus high levels of parental impairment. Two "complex trauma" subgroups were characterized by histories of either physical abuse or sexual abuse with multiple perpetrators, as well as extensive out-of-home placement and severe parental impairment. All subgroups had similar profiles of psychiatric diagnoses. Complex trauma status was associated with behavior problem severity and lower body mass index over and above the effects of psychiatric diagnoses, gender, and ethnicity. Although abuse history was a factor in subgroup membership, the multiple out-of-home placements variable was the most consistent correlate of externalizing and internalizing problems and psychosocial impairment.
Conclusions: Childhood adversity that may constitute complex trauma was associated with externalizing behavior problems and psychosocial impairment among psychiatrically hospitalized children, and this association cannot be accounted for fully by existing psychiatric diagnoses, gender, or ethnicity.
Submitted: October 6, 2008; accepted January 19, 2009.
Online ahead of print: June 30, 2009.
Corresponding author: Julian D. Ford, PhD, 263 Farmington Ave, MC1410, Farmington, CT 06030 ([email protected]).
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