Introduction: Focus on Childhood and Adolescent Mental Health May 2015

Introduction

The Focus on Child and Adolescent Mental Health section in this issue of JCP features 2 articles on bipolar disorder: one addresses course of attention-deficit/hyperactivity disorder (ADHD) in youth who have parents with bipolar disorder, and the other evaluates possible precursors of bipolar disorder. This month’s section also includes a study examining the skeletal effects of selective serotonin reuptake inhibitors (SSRIs) and second-generation antipsychotics.

Offspring of parents with bipolar disorder are at high risk of ADHD in addition to bipolar disorder. Kim and colleagues examined the psychopathology and course of ADHD symptoms in offspring of parents with bipolar disorder compared to offspring of healthy parents or parents with nonbipolar psychopathology (control parents). Study participants were 122 offspring with ADHD who had parents with bipolar I or II disorder and 48 offspring with ADHD who had control parents. Kim and colleagues examined the psychopathology and course of ADHD symptoms in 122 offspring of parents with bipolar I or II disorder compared to 48 offspring of healthy parents or parents with nonbipolar psychopathology (control parents). Semistructured diagnostic interviews of the children were conducted at intake and every other year over a 6-year period. ADHD symptoms and a global assessment of functioning were assessed at each of these time intervals. The retention rate for the study was approximately 90%, with no significant difference between the 2 groups.

Is there a difference in the development course of ADHD symptoms in youths whose parents have bipolar disorder compared to youth whose parents do not? At intake, offspring of parents with bipolar disorder had significantly more severe ADHD symptoms of inattention and hyperactivity than offspring with ADHD of control parents. However, hyperactivity and impulsivity decreased significantly over time for both groups of offspring. No differences between the 2 groups were found in global functioning over time. A higher lifetime prevalence of bipolar spectrum disorders, depression, anxiety disorders, and elimination disorders was found in the offspring of parents with bipolar disorder compared to offspring of the control parents. Importantly, offspring with ADHD of parents who had bipolar disorder did not show a significantly higher lifetime prevalence of bipolar I disorder than offspring with ADHD of control parents. The investigators conclude that the longitudinal course of ADHD symptoms is similar for offspring of parents with bipolar disorder compared to offspring of control parents. However, offspring of parents with bipolar disorder have higher lifetime prevalence of other disorders such as anxiety and depression, which may necessitate treatment.

Selective serotonin reuptake inhibitors (SSRIs) and second-generation antipsychotics are frequently used for extended periods to treat a wide range of psychiatric disorders in children and adolescents. In a prior study, Calarge and colleagues found lower bone mass in children and adolescents treated with SSRIs and risperidone. These investigators conducted an 18-month follow-up study to examine the longitudinal skeletal effects of SSRIs and risperidone in children and adolescents. Ninety-four boys who had previously received risperidone for 6 months or more participated in this follow up study. Most of the boys had received risperidone for 2½ years at study entry. The mean age of the boys was 11.8 years. Data were obtained using markers of bone formation and bone reabsorption and using skeletal scans to assess bone mass. Approximately 25% of these boys had discontinued risperidone by follow-up.

Risperidone use was associated with decreased trabecular bone mass, which worsened over time, with a lack of accrual of bone mass. Although SSRIs were associated with reduced bone mass at study entry and follow-up, there was no significant decline in bone mass between these 2 time points. It is unknown whether youth treated with these medications for long periods of time are at risk for bone fracture. The investigators recommend careful monitoring of children who receive these medications and suggest that clinicians promote healthy lifestyle habits such as nutrition and exercise that may aid in increasing bone mass.

Bipolar illness is a significantly impairing disorder for children and adolescents. Early identification with more rapid treatment intervention may improve the long-term prognosis. Faedda and colleagues conducted a systematic review of prospective studies to identify precursors of bipolar disorder. The prospective longitudinal studies had to have at least 2 structured clinical assessments at intake and follow-up, with a diagnostic outcome of bipolar I or II disorder. Twenty-six studies were included in the meta-analysis. Of those, 6 studies included child and/or adolescent subjects, 12 studies included adult subjects, and 8 studies included children, adolescents, and adults. The follow-up ranged from 6 months to 31 years.

Mood lability, subsyndromal hypomanic symptoms with or without major depression, subsyndromal depression, major depression, cyclothymic disorder, bipolar disorder not otherwise specified, and major depression with psychotic features were precursors of bipolar disorder. Early age at onset of major depression increased the risk of subsequent bipolar disorder. The authors also found that a greater number of lifetime depressive episodes, longer depressive episodes, higher recurrence rates of depression, and more hypomanic symptoms were predictive of later bipolar disorder. The investigators note that it took years to develop bipolar disorder and that early recognition of these precursors may lead to earlier treatment invention. In an accompanying online commentary, Singh provides an insightful perspective on whether there is validity to a bipolar prodrome.

Karen Dineen Wagner, MD, PhD

kwagner@psychiatrist.com

J Clin Psychiatry 2015;76(5):597-598 (doi:10.4088/JCP.15f10015).

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