Almost Bipolar: How to Identify Youth at Risk

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RESEARCH UPDATE

There’s a new diagnostic concept in child psychiatry: The bipolar prodrome. It refers to children who are at risk for bipolar disorder but don’t have the full illness. Research in this area is gathering steam, and nearly all of it focuses on adolescents whose parent has bipolar disorder. This group clearly has an elevated risk, but what signs indicate that the risk is impending?

Researchers at the University of Pittsburgh arrived at an interesting conclusion.¹ It’s not the type of symptoms but their severity that predicts conversion to bipolar in the children of parents with bipolar disorder. They followed 412 adolescents over 10 years, carefully measuring a wide array of psychiatric symptoms to see which ones predicted conversion. Surprisingly, no particular symptom cluster stood out, including mania, depression, anxiety, and mood lability. Rather, it was severity-the number of symptoms and degree of impairment-that best predicted the risk.

The study’s intention was to develop a risk calculator to estimate the chance of developing bipolar disorder, just as similar risk calculators are used to assess the risks of heart attacks, cancer, and diabetes. The Bipolar Risk Calculator compared favorably with its medical cousins in terms of sensitivity and specificity. It’s easy to access, but cumbersome to perform, comprising 120 items across 5 rating scales.²

The study’s take home point, however, can be put into practice right away. Regardless of the symptoms that a child presents with, careful monitoring for hypomania is needed if the problems are significant and the parent has bipolar disorder. Most first-line psychiatric medications can hasten the onset of bipolar, and a new algorithm is available to guide the treatment of this vulnerable population. More on that in our next column.

Disclosures:

Dr. Aiken is the Director of the Mood Treatment Center, Editor in Chief of The Carlat Psychiatry Report, and Instructor in Clinical Psychiatry at the Wake Forest University School of Medicine. He does not accept honoraria from pharmaceutical companies but he but receives honoraria from W.W. Norton & Co. for Bipolar, Not So Much, a book he coauthored with Jim Phelps, MD.

References:

1. Hafeman DM, Merranko J, Goldstein TR, et al. Assessment of a Person-Level Risk Calculator to Predict New-Onset Bipolar Spectrum Disorder in Youth at Familial Risk.JAMA Psychiatry, 2017;74:841-847.

2. University of Pittsburgh Child and Adolescent Bipolar Spectrum Services. Risk Calculator to evaluate the risk to develop Bipolar Spectrum Disorders. http://pediatricbipolar.pitt.edu/resources/risk-calculator-evaluate-risk-develop-bipolar-spectrum-disorders. Accessed May 16,2018.