Bipolar in youth

Bipolar Disorder in Youth
Dale Wisely, Ph.D.
Clinical Psychologist
Director of Student Services
Mountain Brook Schools

A very short summary of the controversy
The controversy: Increase in diagnosis in last 10-15 years. Is it overdiagnosed? How should we understand bipolar disorder in general and in children and teenagers in particular? Do kids get it? How do we know? How does the illness manifest differently in children, teenagers, adults?

This is difficult.
Highly complex, difficult, controversial matter.
“…this debate raises important issues regarding the implications of labeling children with a major psychiatric disorder, especially one that warrants treatment with aggressive psychopharmacology.” (AACAP, 2007)

Bipolar Disorder, An Issue of Child and Adolescent Psychiatric Clinics (Hardcover) by Jeffrey I. Hunt MD (Editor), Daniel P. Dickstein MD (Editor) April 2009, Vol. 18, No. 2

Excellent review article
“Practice Parameter for the Assessment and Treatment of Children and Adolescents with Bipolar Disorder,” Journal of American Academy of Child and Adolescent Psychiatry, 46:1, January 2007.
http://tinyurl.com/bipolarparameters

Very good overview for layperson
NIMH “Bipolar Disorder” webpage
http://tinyurl.com/nimhbipolar

Bipolar illness
Also known as manic-depressive illness
Brain disorder that causes unusual shifts in mood, energy, activity levels, and ability to carry out day-to-day tasks.
Severe symptoms. Different from normal ups and downs.
Can result in damaged relationships, poor job or school performance, and even suicide.
With treatment can lead full and productive lives.

What is the distinguishing feature of bipolar disorder?
Not so much much “mood swings” as…
The presence of mania.

Bipolar?: Often uncertain even in adults.
Is mania a spectrum that ranges from severely psychotic, agitated behavior to merely “energetic” behavior bordering on normal?
Is depression punctuated by fluctuations of mood? Does that make it bipolar?
What’s the difference between bipolar and “mood swings” as part of personality?

BRIEF history….
For much of the 2oth century, there was controversy about whether youth should be diagnosed with and treated for severe mood disorders.
Almost never diagnosed until early 1980s.
1980’s - present: Growth of acceptance that preadolescent children might be bipolar.
1995 - present: Rapid increase in diagnosis in youth (and probably adults as well)

Now
“have we gone too far?”

New controversies…
In general, the influence of the pharmacological companies on research and practice. ($)
In particular, how is this impacting…
Childhood disorders and drug treatment
Bipolar
ADHD
At center: Joseph Biederman, M.D. and others.

“The concern is that the ‘bipolar’ label often might be inappropriately applied to youths whose emotional and behavioral issues might actually not be a manifestation of the same illness connoted by that label in adults.”
Youngstrom, Meyers, et al. (2006)

A bottom line?
Children diagnosed with bipolar are typically given powerful medications.
Unfortunately, that they are diagnosed and treated for bipolar is not the same as saying they have it.

Assessment

Assessment
Must consider present symptoms and evidence of past symptoms.
Looking for mood episodes.
Major depressive episodes
Dysthymic episodes
Hypomanic episodes
Manic episodes
Mixed episodes

Basic range of mood
Major depression
Dysthymia
Hypomania
Mania

Mixed State
Major depression
Dysthymia
Hypomania
Mania
Mixed States: At one time, patient has symptoms of depression and mania

Symptoms of mania in pediatric BP

Mania vs. hypomania
Both occur in “episodes”
Officially: Must persist at least for days (not hours) (DSM-IV)
Mania: Causes marked impairment in functioning, or necessitates hospital, or can cause psychotic features.
Hypomania: Not normal, but doesn’t cause marked impairment, hospitalization, or psychotic features.

Mixed states
One can be seriously depressed, manic, or in a “mixed state.”
symptoms of mania or hypomania and symptoms of depression occur simultaneously.
may experience impulsiveness, insomnia, irritability, flight of ideas (mania)
suicidal thoughts, guilt, feelings of hopelessness, and changes in appetite (depression)

Irritability

Irritability
Long recognized as a feature of mania in some patients, RATHER than euphoria.
In juvenile mania, irritability, belligerence, may be more common than euphoria.
Can be difficult to distinguish from “normal” irritability associated with childhood/adolescence.

DSM-IV bipolar illnesses
Bipolar I
Bipolar II
Cyclothymia

Bipolar I
Generally the most serious & most researched. Diagnosed with even ONE true manic episode (or mixed episode)

Bipolar II
At present and/or in history, patient has
Major depression
Hypomanic episode
No full mania in Bipolar II, but hypomania.
Without careful review of history, can easily be misdiagnosed as major depression.

Cyclothymic Disorder
Hypomanic episode, past or current
Dysthymic episode, past or current
Rarely used diagnosis and not very well researched.

How frequent are cycles and how long do they last?
Classically, in adults, episodes last at least 7 days, unless hospital is required.
Bipolar advocates believe that children cycle more frequently.
DSM: “Rapid Cycling”: Four or more distinct mood episodes in a year.
“Ultrarapid Cycling”: Brief, frequent manic episodes lasting hours to days.
“Ultradian Cycling”: Episodes of minutes to hours, occurring DAILY.

A mood disorder diagnosis matrix
Eric Youngstrom et. al. (2009)

Prevalence: Adults
Bipolar I: 1% of adult population
Bipolar I or II: 3-4% of adult pop.
Spectrum: 3-8% (?)
Community school survey of older adolescents (14-18 years). Lifetime prevalence of about 1%.

Runs in families?
Subjects: 338 children, 6-18 years of 233 parents with bipolar disorder and compared to matched controls.
Children of parents with BP > 13 times more likely to have a bipolar spectrum disorder at time of study & 5 times more likely to have any mood disorder.
Birmaher, et. al. Arch. of Gen. Psychiatry, 66,287-296.

Clinical red flags that should trigger evaluation for PBD
Family history of bipolar illness
Manic symptoms when treated with antidepressants
Rapid switching between depressive and manic symptoms, or both at same time.
Early (<25 years) onset of depression (First clinical episode is depression. Children with true clinical depression at high risk for bipolar illness.
Episodic aggression and rage, especially when high-energy, reactive, unplanned.

Clinical matters….
Mania in youth is frequently associated with psychotic symptoms.
Early onset of bipolar illness associated with more chronic and more severe impairment, perhaps more lifetime risk of suicide.`
In juvenile mania, irritability, belligerence, may be more common than euphoria.

Differential diagnosis
Major depression
Schizophrenia
ADHD
General medical conditions (?)
Substance-induced mood manifestations
Borderline Personality Disorder
Complex co-occurring psychiatric/developmental disorders.

Bipolar vs. ADHD
In both ADHD and mania, hyperactivity, distractibility, intrusiveness, poor judgment, volatile and irritable behavior…impulsive risk-taking, poor sleep habits, and denial of problems prevail…One cannot depend on…a history of euphoria, since its absence does not rule mania out and its presence is very hard (to establish). (G. Carlson, 1990)

Bipolar disorder vs. ADHD
Extremely difficult and controversial matter.
Estimated rate of childhood hyperactivity in adults with bipolar disorder is 10-20%.

Bipolar vs. ADHD
1998 study comparing ADHD group and BP group:
BP group > ADHD
Elevated mood
Grandiosity
Hypersexuality
Decreased need for sleep
Racing thoughts
No difference in high-energy, distractibility

Commonly co-occurring
ADHD
Substance abuse
Anxiety disorders
Oppositional Defiant Disorder
Conduct disorders

Treatment

Medication
Treatment of mania
Treatment of bipolar depression
Maintenance treatment
Relatively little scientific data to guide med selection.
Combination therapy routine
Treatment of co-occurring conditions often involved.

Treating mania
Lithium
Antiepileptics
divalproex (Depakote)
carbamazepine
(Tegretol)
Atypical antipsychotics
risperidone (Risperdal )
olanzapine (Zyprexa)
quetiapine (Seroquel )
ziprasidone (Geodon)
aripiprazole (Abilify)

Lithium
Good News
Bad news
Requires careful monitoring. Every 3-6 months
Li levels
Renal & thyroid fnx
urinalysis
Side effects: nausea, vomiting, diarrhea, hypothyroidism, kidney problems, weight gain, tremor, acne, drug interactions.
FDA approved down to age 12.
Often effective.
Probably should be 1st line mood stabilizer.
Decades of use. Safe when carefully monitored.

antiepileptics
GOOD news
Bad news
There are other potential mood stabilizers besides lithium!
Limited and somewhat mixed data on efficacy and safety.
A wide range of potential side effects too numerous to list. Weight gain, hepatic failure, pancreatitis, hair loss, Stevens-Johnson syndrome.

atypical antipsychotics
Controversy because of alleged collusion between manufacturers and researchers.
Significant weight gain common, resulting in diabetes mellitus, among other metabolic problems.
Careful monitoring essential.

Guidelines: Child & Adolescent Bipolar Foundation (CABF)
Try monotherapy with one of the above agents.
Augment with a second agent if required, third if necessary.

Treatment of (bipolar) depression
High risk of suicide in youth & adults. Bipolar depression probably riskier than unipolar depression.
SSRIs may help, but….
SSRIs may cause or exacerbate mania in youth with bipolar disorder.
If patient taking antidepressant, probably should also be on a mood stabilizer.
All of the medications for mania may help with bipolar depression.

Maintenance therapy
Should patients remain on medication during periods of normal mood?
Most with Bipolar I should, to prevent relapse. Relapse rate as high as 90% without maintenance therapy, as low as 37% with maintenance.
Probably will need lifelong maintenance treatment.
(AACAP, 2007)

Other therapeutics
ECT in severe, intractible cases, especially with psychosis.
Psychotherapy and other support
Various nutritional supplements proposed
OMEGA-3 fatty acids getting some respect. Early data is sparse and mixed.
inositol is an isomer of glucose, present in beans, grains, nuts ,many fruits. Sometimes labeled vitamin B8. Good bit of data with adults—may be effective adjunct treatment.
St John’s Wort. Mixed results.

Is BP overdiagnosed?
Huge increase in diagnosis since early 90’s
“Pediatric BP just doesn’t look like adult BP.”
Ok, so maybe it’s not BP.
Comorbidity is routine in child psychiatry. Maybe some youth diagnosed with BP just have very complex comorbidities.
Ultrarapid cycling and ultradian cycling concepts suspect to some.

Overdiagnosed?
In 1 recent study, half of adult outpatients who had been told they were bipolar met criteria when carefully interviewed. Zimmerman, et. al. J Clin Psychiatry. 2008.
Introduction of the bipolar spectrum, like the autism spectrum, may lead to DIAGNOSIS DRIFT.

special thanks to
Mountain Brook Board of EducationTom B. Vaughan, M.D.

Bipolar Disorder in Youth
Dale Wisely, Ph.D.
Clinical Psychologist
Director of Student Services
Mountain Brook Schools

Bipolar in youth

by dwisely on Jul 07, 2011

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