The Journal of Pediatrics
Volume 150, Issue 5 , Pages 459-460, May 2007

Childhood Onset Bipolar Disorder: A Role for Early Recognition and Treatment

  • Russell E. Scheffer, MD

      Affiliations

    • Corresponding Author InformationReprint requests: Russell E. Scheffer, MD, Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee, WI 53226.

Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee, WI

Article Outline

 

Bipolar disorder is a serious mental illness that affects approximately 3% of the adult population.1, 2, 3 Additional epidemiological surveys have indicated incidence rates up to 7%. In contrast to previous thought, two-thirds of adult patients diagnosed with bipolar disorder began having symptoms in childhood or adolescence,4, 5 and between 25% and 33% of youth who initially present with depression will ultimately become manic.6

See related article, p 485

The diagnosis of bipolar disorder suffers from two common phenomena in medicine: overdiagnosis and underdiagnosis. Clinicians faced with seriously disturbed and aggressive youth may make a serious diagnosis, that is, bipolar disorder, to obtain needed care for these children and adolescents. Not making the diagnosis, on the other hand, may result from clinicians not wanting to “label” a child or frequently not adequately assessing for the condition. Most people identified as having bipolar disorder in epidemiological surveys had either no diagnosis (50%) or were incorrectly diagnosed with depression (31%).7

The failure of clinicians to identify bipolar disorder is frequently a result of the cross-sectional nature of episodes of care. Few patients complain during the early stages of mania. Instead, they frequently present for medical treatment because of somatic complaints associated with depression. Without direct, pointed inquiry, symptoms of mania may go undetected for many years.

In this issue of The Journal, Leverich et al8 from the Stanley Medical Research Institute Bipolar Centers describe findings that significant delay in treatment of bipolar disorder results in negative consequences on outcome and a more treatment-resistant form of the illness. In this important study, 480 adults with bipolar disorder were evaluated to determine their age at first onset of manic or depressive symptoms and the age of first treatment in relationship to the course of the illness. Patients who had earlier onset of illness (childhood or adolescence), in general, had longer delays to appropriate treatment. In addition, these same patients suffered more episodes of affective illness, had more co-morbidities, and experienced rapid mood cycling (a predictor of poor outcome and treatment refractory status).

This long delay to diagnosis and treatment is unfortunately very common. Prolonged illness and recurrent episodes of illness appear to have the effect of making the condition more difficult to treat. Long delays in treatment, as described in this article, can have detrimental effects on patient outcomes, similar to many other illnesses.

Geller et al9, 10 have described a group of youth with prolonged symptoms of mania and poor outcomes, including failure to recover from mania. Unfortunately, in this group the poor outcome may be more easily explained by the poor quality of treatment received including many not receiving any mood stabilizer. The failure to recover was most likely the effect of treating physicians not using mood stabilizers in many of the youth. Whether this was because of diagnostic differences or lack of knowledge about the treatment of bipolar disorder is unclear. These findings are in contrast to emerging data that suggest that youth diagnosed with bipolar disorder and given adequate treatment respond in a similar manner to those with adult-onset illness. In regards to the older patients in the Leverich article, there are now many new and possibly safer treatments FDA approved for adults with bipolar disorder. Many of these agents have positive studies in youth with bipolar disorder. FDA approval for use in youth is still lacking with the exception of lithium, which is now formally being studied.

The childhood onset of bipolar disorder symptoms is apparently more common in the United States than in Europe.11 A possible theory is that immigration status differences (group selection) may account for some of the differences noted across the Atlantic Ocean. Selection regarding those who chose the risky path of transatlantic immigration may have resulted in some differences in conditions where impulsivity plays a significant role, that is, bipolar disorder. It is also possible that other forms of selection bias or reasons for lack of recognition of bipolar disorder could account for the differences between identified rates in the United States and Europe.

The information contained in this article and additional evidence suggest that early detection, diagnosis, and treatment are essential for determining effective treatment outcomes and subsequently, quality of life for those afflicted with bipolar disorder. Collaboration between primary care and psychiatry is essential in making an impact upon bipolar disorder and other serious psychiatric conditions. Screening and early identification by primary care providers and early treatment or referral to psychiatric care, when available, can have a positive impact upon the outcome for these youth.

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References 

  1. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:593–602
  2. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:617–627
  3. Kessler RC, Demler O, Frank RG, Olfson M, Pincus HA, Walters EE, et al. Prevalence and treatment of mental disorders, 1990 to 2003. N Engl J Med. 2005;352:2515–2523
  4. Lish JD, Dime-Meenan S, Whybrow PC, Price RA, Hirschfeld RM. The National Depressive and Manic-depressive Association (DMDA) survey of bipolar members. J Affect Disord. 1994;31:281–294
  5. Perlis RH, Miyahara S, Marangell LB, Wisniewski SR, Ostacher M, DelBello MP, et al. Long-term implications of early onset in bipolar disorder: data from the first 1000 participants in the systematic treatment enhancement program for bipolar disorder (STEP-BD). Biol Psychiatry. 2004;55:875–881
  6. Geller B, Zimerman B, Williams M, Bolhofner K, Craney JL. Bipolar disorder at prospective follow-up of adults who had prepubertal major depressive disorder. Am J Psychiatry. 2001;158:125–127
  7. Calabrese JR, Hirschfeld RM, Frye MA, Reed ML. Impact of depressive symptoms compared with manic symptoms in bipolar disorder: results of a U.S. community-based sample. J Clin Psychiatry. 2004;65:1499–1504
  8. Leverich GS, Post RM, Keck PE, Altshuler LL, Frye MA, Kupka RW, et al. The poor prognosis of childhood onset bipolar disorder: the need for earlier recognition and treatment. J Pediatr. 2007;150:485–490
  9. Geller B, Craney JL, Bolhofner K, Nickelsburg MJ, Williams M, Zimerman B. Two-year prospective follow-up of children with a prepubertal and early adolescent bipolar disorder phenotype. Am J Psychiatry. 2002;159:927–933
  10. Geller B, Tillman R, Craney JL, Bolhofner K. Four-year prospective outcome and natural history of mania in children with a prepubertal and early adolescent bipolar disorder phenotype. Arch Gen Psychiatry. 2004;61:459–467
  11. Post RM, Luckenbaugh DA, Leverich GS. Increased rate of childhood onset bipolar illness in the US compared with two European countries. Brit J Psychiatry. In Press.

PII: S0022-3476(07)00184-9

doi:10.1016/j.jpeds.2007.02.058

Refers to article:

  • The Poor Prognosis of Childhood-Onset Bipolar Disorder

    Gabriele S. Leverich, Robert M. Post, Paul E. Keck, Lori L. Altshuler, Mark A. Frye, Ralph W. Kupka, Willem A. Nolen, Trisha Suppes, Susan L. McElroy, Heinz Grunze, Kirk Denicoff, Maria K.M. Moravec, David Luckenbaugh
    The Journal of Pediatrics May 2007 (Vol. 150, Issue 5, Pages 485-490)

The Journal of Pediatrics
Volume 150, Issue 5 , Pages 459-460, May 2007

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