Bipolar disorder (BPD) is a difficult illness to diagnose in adults and even harder in children and adolescents. The teenage years are tumultuous, and there are mood and anxiety issues associated with this age group which can be misleading. There are multiple controversies, but recent studies have helped provide tips for clinicians for diagnosis as well as treatment.
The DSM-5 criteria require the presence of a manic episode, while the International Statistical Classification of Diseases 10th edition (ICD-10) needs a manic as well as a depressive episode for diagnosis. The DSM-5 recognizes the bipolar spectrum such as bipolar -II and BP-NOS, while ICD-10 does not.
Recent evidence suggests that youth presenting with chronic irritability are unlikely to have BPD. There is a consensus that DSM criteria implementation can help achieve a diagnosis of BPD accurately. The type of BPD also predicts impairment. Those with BP-1 have a greater functional impairment, more likely to attempt suicide, psychiatric hospitalizations, and also have a greater likelihood of having psychotic symptoms. The other subtypes of BPD are less stable across the lifespan. Please note that longitudinal data has revealed that 25% of BP-II convert to BP-I, and 38% of those with BP-NOS/cyclothymia converted to BP-I/BP-II over four years.
Poor outcomes are associated with early age of onset, low socioeconomic status, and a family history of mood disorders. BPD is highly heritable and hence we should get a careful family history.
The prevalence of BPD is 1 in 200 across the globe, but the rate of subthreshold symptoms is much higher at 4.3%. The rates in the US and other European countries are the same. This was based on a large metanalysis of 12 epidemiological studies and another study comparing Dutch and US patients with BPD. Studies have reported lower rates in Africa and Asia than in other parts of the world.
The rates of manic symptoms were similar across studies: the most common was increased energy (79%), followed by irritability (77%), and mood lability 76%. Studies revealed 82% recovered from their index mood episode after 2.5 years. There was a high recurrence (63%) 1.5 years after recovery. Age of onset of illness is an important marker indicating earlier onset is associated with greater functional impairment (employment, living independently, marriage and children, and education). There is an earlier age of onset in the US than in Europe, reasons being unclear. The most common comorbid diagnosis is ADHD in children, while substance use disorder is most common in adolescents.
Diagnostic interviews should assess core symptoms specific to BPD such as elevated mood, grandiosity, decreased need for sleep, and racing thoughts. Besides, one should review the longitudinal course and spontaneous episodicity. It is important to pay attention to the maternal and paternal family history of psychiatric illness. In the case of ADHD, it is important to ascertain whether hyperactivity and distractibility have occurred in the context of the mood episode.
The medication treatment in youth is guided by the phase of the illness. Lithium and the atypical antipsychotics are safe and effective for the short-term management of acute manic and mixed-phase. Some of these include risperidone, olanzapine, quetiapine, aripiprazole, ziprasidone, and asenapine. The depressive phase is harder to treat. The combination of olanzapine and fluoxetine is effective in bipolar depression. Lurasidone is also effective for bipolar depression. Quetiapine though efficacious in adults, did not separate from placebo in depressed children and adolescents. Lamotrigine is effective in maintaining euthymic mood in adolescents 13-17 years of age compared with younger children. Meta-analyses have revealed greater efficacy of second-generation antipsychotics compared with anticonvulsants and lithium.
Combinations treatments, such as lithium or divalproex with an atypical antipsychotic, are effective for treating manic symptoms especially if there is a partial response to one agent. Psychosocial interventions must always be included.
Findings on imaging modalities are similar to adults except the amygdala volumes are smaller in youth compared with controls. The modalities include MRI, Diffusion tensor imaging (DTI), and functional MRI (fMRI). The findings reveal hyperactivation of the amygdala, prefrontal, and visual system and hyperactivation of the anterior cingulate cortex.
There has been great progress in the field of childhood psychiatric disorders. There appears to be an international consensus regarding the validity of the DSM criteria for diagnosing BPD in children and adolescents. The prevalence of BP-1 and BP-II is similar in Europe and the US while lower in Asia and Africa. It is important to pay attention to the core symptoms of BPD and longitudinal history and episodicity of mood symptoms in making the diagnosis. It is important to pay attention to family history. Atypical antipsychotics are effective in treatment as monotherapy or in combination with lithium or divalproex in controlling manic/mixed states. Lurasidone (FDA approved 13-17years), olanzapine and fluoxetine combination, and possibly cariprazine (not approved in adolescents but in adults) are helpful in bipolar depression. It is important to monitor for side-effects including metabolic effects and tardive dyskinesia. Always include psychosocial interventions.