Course of Subthreshold Bipolar Disorder in Youth: Diagnostic Progression From Bipolar Disorder Not Otherwise Specified

Abstract

Objective To determine the rate of diagnostic conversion from an operationalized diagnosis of Bipolar Disorder Not Otherwise Specified (BP-NOS) to Bipolar I or Bipolar II Disorders (BP-I/II) in youth over prospective follow-up and to identify factors associated with conversion. Method Subjects were 140 children and adolescents recruited from clinical referrals or advertisement who met operationalized criteria for BP-NOS at intake and participated in at least one follow-up evaluation (91% of initial cohort). Diagnoses were assessed at follow-up interviews using the Longitudinal Interval Follow-Up Evaluation. The mean duration of follow-up was 5 years and the mean interval between assessments was 8.2 months. Results Diagnostic conversion to BP-I/II occurred in 63 subjects (45%): 32 (23%) to BP-I (9 of whom had initially converted to BP-II) and 31 to only BP-II (22%). Median time from intake to conversion was 58 weeks. First or second-degree family history of mania or hypomania was the strongest baseline predictor of diagnostic conversion (p=.006). Over follow-up, conversion was associated with greater intensity of hypomanic symptoms and with greater exposure to specialized, intensive outpatient psychosocial treatments. There was no association between conversion and exposure to treatment with particular medication classes. Conclusions Children and adolescents referred with mood symptoms that meet operationalized criteria for BP-NOS, particularly those with a family history of BP, frequently progress to BP-I or BP-II disorders. Efforts to identify these youth and effectively intervene may have the potential to curtail the progression of mood disorders in this high-risk population.

Early Intervention for Symptomatic Youth at Risk for Bipolar Disorder: A Randomized Trial of Family-Focused Therapy

“…[1][2][3]6,7 The duration of follow-up in this study was too short to determine whether the short-term effects of FFT-HR on mood recovery translated into a lower risk of later conversion to BD I or II. Future studies may establish whether early interventions that hasten and sustain remission from mood episodes among high-risk youth-particularly those in high conflict familieshave downstream effects that contribute to the delay or prevention of the full bipolar syndrome.…”

“…Of the 40 participants, 30 (75.0%) received ongoing medication sessions from study psychiatrists (mean 6.27 ± 3.34 visits, range [2][3][4][5][6][7][8][9][10][11][12][13][14]. Patients in FFT-HR and EC did not differ at randomization on use of mood stabilizers, atypical antipsychotics, psychostimulants, or antidepressants (all ps > .10) and were equally likely to receive followup medication management from a study psychiatrist (χ 2 [1] = 0.03, p = .86).…”

“…2,5 When combined with a family history of mania in first-or second-degree relatives, more than 50% of youth with BD-NOS progress to fully syndromal BD I or II over 5 years. 6 Children or adolescents with major depressive disorder (MDD) also have elevated risk of conversion to BD I/II (15%-49%) in the 2-4 years after onset of their first depressive episode. 3,7 Conversion to BD I or II is highest among depressed patients with a family history of mania, early onset of symptoms, subthreshold hypomania, psychosis, or episodic mood lability (e.g., 8,9 ).…”

A Randomized Controlled Trial of Individual Family Psychoeducational Psychotherapy and Omega-3 Fatty Acids in Youth with Subsyndromal Bipolar Disorder

“…Youth with BP-I, however, had more functional impairment, suicide attempts, psychosis, and hospitalization than youth with BP-NOS. In longitudinal analyses, approximately one third of youth with BP-NOS met criteria for BP-I or BP-II within 2-4 years (Axelson et al 2011). Additionally, BP-NOS manifested longer time to recovery, more frequent mood shifts, and more time in subsyndromal mood states than BP-I and BP-II Birmaher et al 2006).…”

Collaborative Role of the Pediatrician in the Diagnosis and Management of Bipolar Disorder in Adolescents

“…10 Emerging evidence suggests that this disorder is on a continuum with bipolar I disorder, 11,12 and 45% of patients converted to bipolar I or bipolar II disorder at follow-up an average of 5 years later, particularly patients with a family history of bipolar disorder. 13 Beyond DSM-IV-TR Akiskal and Pinto described a bipolar spectrum in adults, ranging from bipolar I disorder to hyperthymic temperament. 4 The disorders and conditions on the spectrum share symptom characteristics that generally responded better to mood-stabilizing medication than to antidepressant medication.…”