Course and Impact of Bipolar Disorder in Young Patients
Kiki D. Chang, MD
Department of Psychiatry and Behavioral Sciences and the Bipolar Disorders Program, Stanford University School of Medicine, Stanford, California
People with an onset of bipolar disorder in childhood have been found to wait an average of more than 16 years until receiving treatment.1 Early intervention may lessen the morbidity and improve the course and outcome of bipolar disorder for children. The earlier the onset of bipolar disorder and the longer the delay until treatment, the worse the functional outcome is. Adults who had childhood onset of bipolar disorder were more likely to have a history of suicidal ideation and suicide attempts, have higher rates of comorbidity, and have more rapid cycling than those who had adult onset (AV 1).2
In a naturalistic study,3 the clinical course of childhood bipolar disorders (I, II, and NOS) was observed for an average of 2 years; children were enrolled regardless of their bipolar state or treatment status. Although the rate of recovery from the index episode was similar for all 3 groups, children who had bipolar disorder NOS recovered more slowly and had a longer time to recurrence than those with bipolar I or II disorder. Among the total sample, more than half of the recurrences were major depressive episodes. Subjects spent about 60% of the follow-up period with syndromal or subsyndromal manic, depressive, or mixed symptoms, and 3% of the time was spent in a psychotic state. At endpoint, 25% of the baseline bipolar disorder NOS diagnoses had converted to bipolar I or II disorder, and 20% of bipolar II disorder cases at baseline had converted to bipolar I disorder.
Over the lifespan, symptoms of bipolar disorder may differ (AV 2).4 Manic episodes, for example, may manifest as rage in children, irritability in adolescents, and euphoria in adults. Although mania predominates in children with bipolar disorder, depressive episodes grow more common as the child gets older. In one study,5 53% of the children and adolescents with bipolar disorder had a history of a major depressive episode, 76% had had suicidal ideation, and 31% had attempted suicide. Thus, clinicians should carefully screen young patients for suicidal ideation.
Bipolar disorder appears to be more episodic in adults than in children because episodes tend to last longer in children.3,6 One longitudinal study6 followed a cohort of children with first-episode bipolar I disorder, manic or mixed phase, for 8 years and found a long mean recovery period (AV 3). At 6 months, the probability of recovery from the first episode was about 30%, and only about half of the children had recovered after 1 year. After 18 months, about two-thirds of the patients had recovered. At year 8, the probability of recovery from the first episode was high, but the probability of relapse was also high. Children who scored low for maternal warmth (the connection between the child and the mother) were more likely to relapse than those with high maternal warmth.
Bipolar disorder in children and adolescents frequently co-occurs with other disorders, particularly ADHD (AV 4).5 In older patients, comorbid ADHD is less common. Anxiety disorders and oppositional defiant disorder are also prevalent among children with bipolar disorder. Anxiety disorders are as common among young patients with bipolar II disorder as ADHD is among those with bipolar I disorder or bipolar disorder NOS.
For Clinical Use
If left untreated, pediatric bipolar disorder becomes chronic, has a high incidence of relapse, and has a poor prognosis, so early recognition and intervention are crucial. The pediatric bipolar spectrum includes subsyndromal and prodromal states because children are still developing. To better recognize bipolar states in young patients, clinicians should:
- Be aware that the presentation of bipolar disorder in children and adolescents may vary from its presentation in adults
- Watch for irritability and rage, which are common manifestations of mania in young people with bipolar disorder
- Expect bipolar mood episodes, especially the first one, to last longer in young patients than in adults
- Screen carefully for suicidal ideation and comorbid disorders such as ADHD and anxiety disorders
ADHD = attention-deficit hyperactivity disorder
NOS = not otherwise specified
ODD = oppositional defiant disorder
PDD = pervasive developmental disorder
SUD = substance use disorder
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- Leverich GS, Post RM, Keck PE Jr, et al. The poor prognosis of childhood-onset bipolar disorder. J Pediatr. 2007;150(5):485–490.
- Carter TD, Mundo E, Parikh SV. Early age at onset as a risk factor for poor outcome of bipolar disorder. J Psychiatr Res. 2003;37(4):297–303.
- Birmaher B, Axelson D, Strober M, et al. Clinical course of children and adolescents with bipolar spectrum disorders. Arch Gen Psychiatry. 2006;63(2):175–183.
- Chang KD, Howe M, Simeonova DI. Treatment of children and adolescents with bipolar disorder. In: Ketter TA, ed. Advances in Treatment of Bipolar Disorder. Washington, DC: American Psychiatric Association; 2005:179–209. Review of Psychiatry; vol 24.
- Axelson D, Birmaher B, Strober M, et al. Phenomenology of children and adolescents with bipolar spectrum disorders. Arch Gen Psychiatry. 2006;63(10):1139–1148.
- Geller B, Tillman R, Bolhofner BS, et al. Child bipolar I disorder: prospective continuity with adult bipolar I disorder; characteristics of second and third episodes; predictors of 8-year outcome. Arch Gen Psychiatry. 2008;65(10):1125–1133.