Prevention of bipolar disorder in at-risk children: Theoretical assumptions and empirical foundations

Abstract

This article examines how bipolar symptoms emerge during development, and the potential role of psychosocial and pharmacological interventions in the prevention of the onset of the disorder. Early signs of bipolarity can be observed among children of bipolar parents and often take the form of subsyndromal presentations (e.g., mood lability, episodic elation or irritability, depression, inattention, and psychosocial impairment). However, many of these early presentations are diagnostically nonspecific. The few studies that have followed at-risk youth into adulthood find developmental discontinuities from childhood to adulthood. Biological markers (e.g., amygdalar volume) may ultimately increase our accuracy in identifying children who later develop bipolar I disorder, but few such markers have been identified. Stress, in the form of childhood adversity or highly conflictual families, is not a diagnostically-specific causal agent but does place genetically and biologically vulnerable individuals at risk for a more pernicious course of illness. A preventative family-focused treatment for children with (a) at least one first-degree relative with bipolar disorder, and (b) subsyndromal signs of bipolar disorder, is described. This model attempts to address the multiple interactions of psychosocial and biological risk factors in the onset and course of bipolar disorder.

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).…”

“…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 ).…”

“…Furthermore, environmental-contextual factors that may increase risk for mood symptomssuch as whether parents exhibit high expressed emotion (EE) attitudes toward the child (i.e., high levels of criticism, hostility, or emotional over-involvement)-may be most amenable to change early in the course of the disorder. 7 Few studies, however, have examined the effects of early psychosocial intervention on youth with high-risk phenotypes. One 12-month waitlist trial found that multi-family psychoeducation groups protected against conversion to bipolar spectrum disorders in a sample of school-aged children with depressive spectrum disorders.…”

Lack of Effect of Stimulant Combination with Second-Generation Antipsychotics on Weight Gain, Metabolic Changes, Prolactin Levels, and Sedation in Youth with Clinically Relevant Aggression or Oppositionality

“…likely that prescribers would have refrained from prescribing stimulants out of fear of inducing mania, thinking that the ADHD symptoms could be part of a bipolar prodrome (Correll et al 2007;Miklowitz and Chang 2008). Nevertheless, studies are needed that directly compare treatment with stimulants versus antipsychotics versus a combination of both for the treatment of maladaptive aggression in youth.…”