Comorbidities in Youth with Bipolar Disorder: Clinical Features and Pharmacological Management

Abstract

Background: Bipolar Disorder (BD) is a highly comorbid condition, and rates of co-occurring disorders are even higher in youth. Comorbid disorders strongly affect clinical presentation, natural course, prognosis, and treatment. Method: This review focuses on the clinical and treatment implications of the comorbidity between BD and Attention-Deficit/Hyperactivity Disorder (ADHD), disruptive behavior disorders (Oppositional Defiant Disorder and/or Conduct Disorder), alcohol and substance use disorders, Autism Spectrum Disorder, anxiety disorders, Obsessive-Compulsive Disorder, and eating disorders. Results: These associations define specific conditions which are not simply a sum of different clinical pictures, but occur as distinct and complex combinations with specific developmental pathways over time and selective therapeutic requirements. Pharmacological treatments can improve these clinical pictures by addressing the comorbid conditions, though the same treatments may also worsen BD by inducing manic or depressive switches. Conclusion: The timely identification of BD comorbidities may have relevant clinical implications in terms of symptomatology, course, treatment and outcome. Specific studies addressing the pharmacological management of BD and comorbidities are still scarce, and information is particularly lacking in children and adolescents; for this reason, the present review also included studies conducted on adult samples. Developmentally-sensitive controlled clinical trials are thus warranted to improve the prognosis of these highly complex patients, requiring timely and finely personalized therapies.

Comorbid Obsessive-Compulsive Disorder and Bipolar Disorder in the Pediatric Population — Clinical and Therapeutic Challenges

“…[5,[8][9][10][11] These results are similar to the 27-45% rate of manic symptoms in OCD both in pediatric and adult populations, [8,10,[12][13][14] but significantly higher when compared to the adult BD population alone, in which much smaller rates of OCD-BD comorbidity are described, only 10-16%. [9,14,15] In a retrospective study with a sample of 207 children and adolescents, the overlap between BD and OCD was bidirectional and symmetrical, with reciprocal comorbidity present in 21% of the youth with BPD and 15% of those diagnosed with OCD. [8] A lower mean age seems to predict a higher prevalence of OCD in BD pediatric patients.…”

“…Adult population: In adults, the lifetime prevalence of comorbidity between OCD and BD appears to be as high as 15% to 35%. [6,8,9] Even though there is emerging literature on this topic, we are still confronted with relatively limited systematic data and randomized trials specifically targeting the clinical characteristics and treatment of these patients. Data regarding the juvenile population is even scarcer, despite the frequent juvenile onset of both OCD and BD symptoms.…”

Examining the Status of Research on Treating Bipolar Disorder in Teenagers and Children

“…Medication and psychotherapy are two equally important components of the multimodal treatment of bipolar illness in children and adolescents. Numerous studies have examined the effects of medications such as lithium, antidepressants, and antipsychotics [13,14]. Lithium in particular has demonstrated promise in reducing suicidal thoughts, depressive symptoms, and psychosocial functioning.…”

“…Moreover, long-term use of lithium salts may be accompanied by potential risks to the kidneys, thyroid function, etc., and therefore the risks and benefits of the drug need to be carefully assessed when formulating a treatment plan. Therefore, potential drug side effects need to be carefully assessed and treatment regimens should be tailored to the individual [13][14][15]. When treating bipolar disorder in children and adolescents with medication, there is greater prudence and conservatism than when treating the condition in adults [9].…”

“…However, it has also been demonstrated that psychotherapeutic, and particularly psychosocial, interventions including family therapy, cognitive behavioural therapy, and supportive therapies, can help patients manage their mood swings and enhance the stability and support of their families [13,16]. In addition, a novel intervention, albeit with preliminary clinical efficacy, is Positive Mindfulness Cognitive Therapy, a psychotherapeutic approach combining Positive Mindfulness and Cognitive Behavioural Therapy, which is designed to help patients become aware of and accept current emotions, feelings and thoughts through positive mindfulness exercises, as well as cognitive skills to change negative patterns of thinking and behavioural habits.…”