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Original Research

Early-Onset Bipolar Disorder and Treatment Delay Are Risk Factors for Poor Outcome in Adulthood

Robert M. Post, MD; Gabriele S. Leverich, LCSW; Ralph W. Kupka, MD, PhD; Paul E. Keck Jr, MD; Susan L. McElroy, MD; Lori L. Altshuler, MD; Mark A. Frye, MD; David A. Luckenbaugh, MA; Michael Rowe, PhD; Heinz Grunze, MD, PhD; Trisha Suppes, MD, PhD; and Willem A. Nolen, MD, PhD

Published: July 15, 2010

Article Abstract

Objective: We examined the influence of age at onset of illness and the delay in time to first treatment on morbidity in adulthood.

Method: 529 adult outpatients with a mean age of 42 years, who entered our research network from 1996 through 2001 and who were diagnosed with bipolar disorder according to DSM-IV criteria, were rated prospectively on a daily basis with the National Institute of Mental Health-Life Chart Method during naturalistic treatment for up to 4 years.

Results: Fifty percent of patients had illness onset in childhood (< 13 years of age) or adolescence (13-18 years of age). In year 1 of follow-up, these patients, compared to those with adult onset, showed significantly (P < .05) greater severity of depression and mania, greater number of episodes, more days depressed, more days of ultradian cycling, and fewer days euthymic. After 4 years, the mean severity and duration of depression remained greater and the number of days euthymic fewer in those with childhood compared to adult onset (P < .05). The delays to first treatment correlated inversely with age at onset of illness. Independently, delay to first treatment was associated with more time depressed, greater severity of depression, greater number of episodes, more days of ultradian cycling, and fewer days euthymic (all P < .05).

Conclusions: These data converge with other evidence that onset of bipolar disorder in childhood is common and often associated with extraordinarily long delays to first pharmacologic treatment. Both childhood onset and treatment delay were associated with a persistently more adverse course of illness rated prospectively in adults. These data should help foster efforts to ensure earlier and more effective treatment of bipolar illness in children and adolescents. It is hoped that appropriate early intervention would result in a more benign illness and a better prognosis in adulthood.

J Clin Psychiatry 2010;71(7):864-872

Submitted: December 22, 2008; accepted June 9, 2009(doi:10.4088/JCP.08m04994yel).

Corresponding author: Robert M. Post, MD, Bipolar Collaborative Network, 5415 W Cedar Lane, Suite 201B, Bethesda, MD 20814 (

Volume: 71

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