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The Health Care Crisis of Childhood-Onset Bipolar Illness: Some Recommendations for Its Amelioration

Robert M. Post, M.D., and Robert A. Kowatch, M.D.

Objective: To describe new data on the incidence and impact of childhood- and adolescent-onset bipolar illness and make recommendations to help accelerate the acquisition of knowledge in this area.

Data Sources: Two large, multicenter outpatient studies in adults with DSM-IV bipolar disorder- the Systematic Treatment Enhancement Program for Bipolar Disorder and the Bipolar Collaborative Network- were the primary sources of retrospective data on age at onset.

Study Selection: We focused on the 2 retrospective studies because they supplied more immediate data on age at onset and long-term prognosis than current prospective studies.

Data Synthesis: The 2 studies revealed that 15% to 28% of adults experienced an onset of their illness prior to age 13 years. Those with childhood versus adult onset had a more severe, complicated, and adverse course of bipolar illness, assessed retrospectively and confirmed prospectively during naturalistic treatment. The time lag from onset of first symptoms to first treatment was strongly inversely related to age at onset and averaged 16.8 ± 10 years in those with childhood onset. Recommendations include defining temporary consensus threshold criteria for each bipolar subtype and their prodromes; conducting studies using less onerous than traditional designs, including randomized open comparisons to acquire preliminary data in this age cohort; and forming clinical and academic treatment outcome networks to more quickly acquire treatment outcome data in this understudied population.

Conclusions: The data reveal a very substantial rate of childhood-onset bipolar illness, extraordinary delays in onset to first treatment, and a very adverse long-term outcome. Several approaches to accelerating the rate of acquisition of treatment outcome data in this cohort are outlined.

(J Clin Psychiatry 2006;67:115-125)

Received May 10, 2005; accepted Oct. 8, 2005. From the Biological Psychiatry Branch, National Institute of Mental Health (NIMH), National Institutes of Health (NIH), Bethesda, Md. (Dr. Post), and the Department of Psychiatry, Cincinnati Children's Hospital Medical Center/University of Cincinnati Medical Center, Cincinnati, Ohio (Dr. Kowatch).

This research was supported (in part) by the Intramural Research Program of the NIMH, NIH.

Dr. Kowatch has served as a consultant to Eli Lilly, GlaxoSmithKline, Janssen, Otsuka, and Cephalon and has served on the speakers or advisory boards of AstraZeneca and Abbott. Dr. Post reports no additional financial or other relationships relevant to the subject of this article.

The views expressed here are solely the personal opinions of the authors and may not reflect the official positions of the NIMH, NIH, the federal government, or any other organization.

Corresponding author and reprints: Robert M. Post, M.D., Chief, Biological Psychiatry Branch, NIMH, NIH, Bldg. 10, Room 3S329, 10 Center Dr. MSC-1272, Bethesda, MD 20892-1272 (e-mail: