Pediatric bipolar disorder 'underrecognized' and needs to be addressed, speaker says

Clinical awareness of bipolar disorder in youth is important given its high morbidity and mortality rate, which is even higher than adult-onset bipolar disorder, according to a presenter at the Psych Congress 2020 Virtual Experience conference.

“Depression and bipolar disorder are still underrecognized in youth overall,” Kiki D. Chang, MD, a child, adolescent and adult psychiatrist with a private practice in California, said during the presentation. “People used to think there was an overdiagnosis, and there certainly was around the turn of the century, where we were diagnosing youth with irritability and anger. Then there was a pendulum swing back in the other direction, which I think we’re still in, since we’re realizing that youth are increasingly having mood disorders, including bipolar disorder and depression.”

Studies have shown that depression occurs among 12% of adolescents and bipolar disorder among 2% of children/adolescents. Bipolar disorder onset during childhood appears to occur between 50% and 67% of the time, according to Chang. Over the past 10 years, community diagnosis of the disorder has increased 40 times, and estimates suggest between 420,000 and 2,072,000 children in the United States may have bipolar 1 or bipolar 2 disorder. Chang noted that children with bipolar disorder are at increased risk for poor psychosocial outcomes.

“The earlier the onset of bipolar disorder, the worse the outcome, which means the younger the onset, the higher the rates of substance use, suicide attempts and school failure,” Chang said.

Early signs of bipolar disorder in youth include ADHD, depression, mood dysregulation and anxiety, particularly if these occur together and/or with a family history of bipolar disorder, according to Chang. Further, clinicians should pay close attention to overall mood change, perhaps by month, since mood vacillations are frequent and common, particularly among younger patients. Other “cardinal symptoms” for which clinicians should watch for include inflated self-esteem or grandiosity; decreased need for sleep; being more talkative than usual; racing thoughts; distractibility; increase in goal-directed activity; and excessive involvement in pleasurable activities that have a high potential for painful consequences.

Chang emphasized that clinicians should be sure to differentiate bipolar disorder from disruptive mood dysregulation disorder, which is a new addition to the DSM-5, and pediatric acute-onset neuropsychiatric syndrome.

He also provided an overview of bipolar disorder treatment for youth via a three-pronged approach: medications, educational interventions and psychotherapy.

Medications for acute mania include lithium, risperidone, aripiprazole, quetiapine, olanzapine and asenapine; for acute depression, olanzapine/fluoxetine and lurasidone; and for longer-term pediatric bipolar disorder treatment, lithium and aripiprazole. However, important unmet needs persist, such as a lack of well-tolerated treatments for acute depression and maintenance.

Chang noted that second-generation antipsychotics offer similar efficacy for mania, and lurasidone and olanzapine-fluoxetine combination appear effective for bipolar depression.

Although combination therapies, maintenance strategies and interventions beyond medications remain understudied, Chang did highlight possible non-pharmacological interventions.

“A lot of the psychotherapy we talk about regarding bipolar disorder has to do with explaining medications to the family, explaining how to prevent episodes from happening, how to get good sleep and doing [cognitive behavioral therapy] or other kinds of things with the child to reduce stress, such as mindfulness,” Chang said. “Without that, you're missing a huge component.

Chang also noted the importance of educational interventions.

“A major part of a child's life is school, and so school can either be a place where the child is not doing well and feeling stressed, or it can be a source of support through things like education and practicing social skills and emotional regulation.”