Bipolar Disorder in Children

Overview

Bipolar disorder is a recurrent and sometimes chronic illness involving episodes of depression and mania or hypomania” (Hirschfeld, 2007). Mania means elevated mood featuring, among other symptoms, grandiosity and irritability, perhaps psychosis; hypomania is a less severe form of mania. Sometimes a person with bipolar disorder experiences “mixed” episodes of both mania and depression. Townsend, Demeter, Wilson, & Findling (2007) report that children with bipolar disorder often experience constant mood instability with little recovery between episodes. They also state that diagnosing and treating the disorder in children remains a challenge, and therefore children with bipolar disorder often go for long periods of time before receiving proper treatment. According to Scheffer (2007), bipolar disorder and attention deficit hyperactivity disorder frequently coexist in children. Dineen Wagner (2006) states that children also frequently suffer from both bipolar disorder and an anxiety disorder. When children with bipolar disorder grow up, they continue to suffer from the disorder (Chang, 2007). “Similar to adults with bipolar disorder, children and adolescents are at increased risk for substance-related disorders, weight problems, and impaired social support systems” (Jolin, Weller, & Weller, 2007). Life events may also influence the course of bipolar disorder in children (Johnson & McMurrich, 2006). Family history of bipolar disorder is a risk factor (Benazzi, 2007).

 

Epidemiology/Impact on Minority Groups

Chang et al. (2006) state that onset of bipolar disorder is typically at about age 18. However, it can appear sooner. Duffy (2007) believes that bipolar disorder does not manifest itself until at least early adolescence. Numerous others, however, imply that the disorder can be present earlier, in preadolescents (e.g., Blader & Kafantaris, 2007). In many countries outside the United States, the rate of diagnosed childhood bipolar disorder is less than that in the U.S., suggesting that the disorder is either underdiagnosed elsewhere or overdiagnosed in this country (Soutullo et al., 2005). One study of adults in England (Lloyd et al., 2005) found no difference in the incidence of bipolar disorder between males and females, but a greater incidence of the disorder among minorities. Grant et al. (2005) found in the United States that Native Americans were at greater risk for bipolar disorder and Asian Americans and Hispanic Americans were at lower risk. They also stated that low socioeconomic status is a risk factor. Nations that consume greater amounts of seafood have been determined to have lesser rates of bipolar disorder among the general population than nations that do not eat as much seafood (Noaghiul & Hibbeln, 2003).

 

Economic Impact

A study by Guo, Keck, Li, & Patel (2007) found that bipolar disorder accounted for 30 percent of Medicaid costs. Another study (Harley et al., 2007) found that the disorder cost a mean of $2,690 per patient in the six months before the first bipolar-related insurance claim and $6,826 in the following year. Stensland, Jacobson, & Nyhuis (2007) stated that the mean cost was $10,402 per patient in a year. Given that bipolar disorder may affect up to 5 percent of the population (Freeman & Freeman, 2006), the societal cost is high.

 

Therapy

Bipolar disorder is treated through a combination of drug therapy and psychotherapy (Townsend, Demeter, Wilson, & Findling, 2007); nutritional therapy may also be used. “Because pediatric bipolar disorder is such a pernicious condition, it is recommended that clinicians complete a careful assessment of mood symptoms and comorbid conditions when this illness is suspected so that they can provide treatments with the best chance of benefit in a timely manner” (Townsend, Demeter, Wilson, & Findling, 2007). Jolin, Weller, & Weller (2007) state that it is important to provide young bipolar patients with strong social support structures. Reduction in stress and improved coping abilities can help stabilize patients (Chang, Howe, Gallelli, & Miklowitz, 2006). During extreme mood episodes, hospitalization may occur (Birmaher & Axelson, 2006).

 

Drug Therapy

Mood stabilizers, such as lithium, carbamazepine, valproate, and lamotrigine, and antipsychotics are the recommended drug therapy for bipolar disorder (Goossens, van Achterberg, & Knoppert-van der Klein, 2007). “Lithium remains the only FDA-approved mood stabilizer for use in children > 12 years of age and along with valproic acid and carbamazepine, forms the triad of traditional mood stabilizers used for initiation of treatment for PBD [pediatric bipolar disorder]. There has been a recent surge in the use of atypical antipsychotics in PBD, which may be due to their relative ease of administration and lack of requirement for serum level monitoring. A combination of traditional mood stabilizers along with atypical antipsychotics is commonly used in clinical practice, despite a lack of compelling empirical data” (Madaan & Chang, 2007). Strawn & Delbello (2008) studied the effects of the antipsychotic drug olanzapine in children, and found that although it was effective in treating mania and mixed episodes, side effects such as weight gain and diabetes made it more feasible as a drug for acute episodes rather than as a maintenance drug for youths. Correll (2007) found that combining mood stabilizers with antipsychotics in treating children led to greater weight gain than treating with mood stabilizers alone. Sometimes antidepressants are used along with other drug treatments for bipolar disorder (Thase, 2006).

 

Nutritional Therapy

Applebaum, Bersudsky, & Klein (2007) performed a study in which selected participants with bipolar disorder were given an amino acid solution that reduced plasma tryptophan. They found that this appeared to reduce manic symptoms, but the drink was not very well tolerated. Sempels & Sienaert (2007) concluded that omega-3 fatty acids can have a beneficial effect on depressive symptoms, but there is no demonstrated benefit for manic symptoms. Parker et al. (2006) similarly found benefits from omega-3 fatty acids for people with mood disorders. Shaldubina et al. (2006) discovered that restricting inositol in the diet helped reduce manic symptoms. El-Mallakh & Paskitti (2001) theorize that a diet called the ketogenic diet, a high-fat (80 percent fat), low-calorie diet (Epilepsy Foundation, 2008) dating from the 1920s and thought to benefit epileptics, may have potential as a mood stabilizer. Naylor & Smith (1981) found that an increase in vitamin C had benefits for both manic and depressive symptoms, and a decrease in vanadium improved bipolar patients’ symptoms as well. Maletzky’s (1979) study concluded that adding a diuretic to lithium therapy or combining lithium with a low-sodium diet had benefits for bipolar patients.

 

Nursing Issues

Goosens, van Achterberg, & Knoppert-van der Klein (2007) note that nurses are becoming increasingly involved in the care of bipolar patients; the quality of that care varies. They state that nurses can help patients learn to manage their illness, and offer support and communication. They add that nurses can help detect symptoms; they also may check patients’ blood levels of medications. During manic episodes, nurses may reduce stimulation and set boundaries (Goosens, van Achterberg, & Knoppert-van der Klein, 2007; McColm, Brown, & Anderson, 2006)), observe the behavior of a patient, such as eating and drinking, to make sure proper nutrition is maintained (McColm, Brown, & Anderson, 2006), and administer tranquilizers (McColm, Brown, & Anderson, 2006). “Nursing a patient with mania remains one of the most challenging experiences for mental health nurses,” according to McColm, Brown, & Anderson (2006), especially since many manic patients do not admit they need help. Nursing patients with depression is also challenging, for nurses must try to prevent patients from acting on suicidal thoughts, and deal with patients’ issues of low self-esteem and despondency (Kerr, 1987-1988). Mental health nursing must be patient-centered and based on a trusting relationship with the patient (McColm, Brown, & Anderson, 2006). “Nurse practitioners can be effective providers by using good nursing practices of communication, education, and advocacy for the patient and family” (Miller, 2006). They also must be familiar with diagnostic criteria (Miller, 2006). School nurses in particular are an important part of preventing children with bipolar disorder from slipping into self-destructive patterns caused by the symptoms of the illness (Olson & Pacheco, 2005).

 

Some Psychological Aspects

Cahill, Green, Jairam, & Malhi  (2007) concluded that certain cognitive deficits begin in adolescent bipolar patients and continue into adulthood. In another study (Serene, Ashtari, Szeszko, & Kumra, 2007), MRIs were taken of children with bipolar disorder, and they were found to exhibit abnormalities in portions of the brain. One study (Harvey, Mullin, & Hinshaw, 2006) found considerable sleep disturbance among youths with bipolar disorder. One risk factor of bipolar disorder is suicide; lithium has been demonstrated to reduce suicide (Freeman & Freeman, 2006).

 

Organizations

 

1. The National Institute for Mental Health, NIMH, conducts research/clinical trials. It provides funding (grants, etc.) for research. It also offers a great deal of information on its Web site (see below).

 

2. The National Alliance for the Mentally Ill, NAMI, provides information about various illnesses, including bipolar disorder, and support for individuals suffering from these illnesses. The group also engages in legislative advocacy and stigma fighting ("stigma busters" - fighting, e.g., negative portrayals of the mentally ill in the media). It holds walks to raise funds. The group’s Web site is filled with information (see below).

 

3. The Depressive and Bipolar Support Alliance, DBSA, holds an annual conference. The group engages in advocacy and sponsors support groups. The group holds various educational programs and events, and raises donations. The Web site offers a wealth of information (see below).

 

Web sites

 

1. The National Institute for Mental Health, www.nimh.nih.gov. The site offers mental health news, details on their clinical trials, information on research grants, information on mental health, including bipolar disorder, a link to a site for finding a provider, and various publications.

2. The National Alliance for the Mentally Ill, www.nami.org. The site offers an "Inform Yourself" section about disorders, including bipolar disorder, and info on support and discussion groups about mental illness in general. There is a link to the groups Advocate magazine (the group does a lot of advocacy and battling of stigma). There is mental health news and an online store, and information on the group's national convention and "walks" to raise money.

3. The Depression and Bipolar Support Alliance, www.ndmda.org. Like NAMI, this group has a national conference, with information about it on the Web site. The site also features a blog by the group's president, and a "share your story" section for people with mood disorders. There is information about mood disorders and a place to send donations. The site gives info about the group's upcoming events and about research. There is news about issues related to mood disorders, and the group does news releases on its activities for the media. The site has an online store.

4. The Mayo Clinic, www.mayoclinic.com. The bipolar disorder section of the Mayo Clinic's site offers basic information on the disorder, symptoms, causes, risk factors, when to seek medical advice, diagnosis, complications, treatment/prevention, self-care/coping skills, and alternative medicine.

5. Everyday Health, www.everydayhealth.com. The bipolar disorder section of the Everyday Health site gives information about bipolar disorder - basic overview, symptoms, diagnosis, treatment/prevention, tips for managing it, medications, etc. The site posts bipolar disorder news. There is an "Ask a Specialist" feature. The site also offers support groups.

 

 References

 

Applebaum, J., Bersudsky, Y, & Klein, E. (2007, December). “Rapid tryptophan depletion for acute mania: a double-blind, pilot-controlled study.”  Bipolar Disorder, 884-887.

 

Benazzi, F. (2007, March). “Bipolar disorder--focus on bipolar II disorder and mixed depression.” Lancet, 935-945.

 

Birmaher, B., & Axelson, D. (2006, Fall). “Course and outcome of bipolar spectrum disorder in children and adolescents: a review of the existing literature.” Deviant Psychopathology, 1023-1035.

 

Blader, J.C., & Kafantaris, V. (2007, March). “Pharmacological treatment of bipolar disorder among children and adolescents.” Expert Revolutionary Neurotherapy, 259-270.

 

Cahill, C.M.,Green, M.J.,,Jairam, R., & Malhi, G.S. (2007, November). “Do cognitive deficits in juvenile bipolar disorder persist into adulthood?” Journal of Nervous Mental Disorders, 891-896.

 

Chang, K. (2007, July). “Adult bipolar disorder is continuous with pediatric bipolar disorder.” Canadian Journal of Psychiatry, 418-425.

 

Chang, K., Howe, M., Gallelli, K., & Miklowitz, D. (2006, December). “Prevention of pediatric bipolar disorder: integration of neurobiological and psychosocial processes.”  Annals of the New York Academy of Sciences, 235-247.

 

Correll, C.U. (2007, June). “Weight gain and metabolic effects of mood stabilizers and antipsychotics in pediatric bipolar disorder: a systematic review and pooled analysis of short-term trials.” Journal of the American Academy of Child and Adolescent Psychiatry, 687-700.

 

Dineen Wagner, K. (2006, Supplement). “Bipolar disorder and comorbid anxiety disorders in children and adolescents.” Journal of Clinical Psychiatry, 16-20.

 

Duffy, A. (2007, July). “Does bipolar disorder exist in children? A selected review.” Canadian Journal of Psychiatry, 409-417.

 

El-Mallakh, R.S., & Paskitti, M.E. (2001, December). “The ketogenic diet may have mood-stabilizing properties.” Medical Hypotheses, 724-726.

Grant, B.F., Stinson, F.S., Hasin, D.S., Dawson, D.A., et al. (2005, October). “Prevalence, correlates, and comorbidity of bipolar I disorder and axis I and II disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions.”  Journal of Clinical Psychiatry, 1205-1215.

 

Epilepsy Foundation. (2008). “Treatment options: Ketogenic diet.” Accessed April 25, 2008, at http://www.epilepsyfoundation.org/about/treatment/ketogenicdiet/

 

Freeman, M.P., & Freeman, S.A. (2006, June). “Lithium: clinical considerations in internal medicine.” American Journal of Medicine, 478-481.

 

Goossens, P.J.J., van Achterberg, T., & Knoppert-van der Klein, E.A.M. (2007, June). “Nursing processes used in the treatment of patients with bipolar disorder.” International Journal of Mental Health Nursing, 168-177.

 

Guo, J.J., Keck, P.E., Li, H., & Patel, N.C. (2007, August). “Treatment costs related to bipolar disorder and comorbid conditions among Medicaid patients with bipolar disorder.” Psychiatric Services, 1073-1078.

 

Harley, C., Li, H., Corey-Lisle, P., L’Italien, G.J., et al. (2007, September). “Influence of medication choice and comorbid diabetes: the cost of bipolar disorder in a privately insured U.S. population.” Social Psychiatry & Psychiatric Epidemiology, 690-697.

 

Harvey, A.G., Mullin, B.C., & Hinshaw, S.P. (2006, Fall). “Sleep and circadian rhythms in children and adolescents with bipolar disorder.” Developmental Psychopathology, 1147-1168.

 

Hirschfeld, R.M. (2007, November). “Screening for bipolar disorder.” American Journal of Managed Care, S164-169.

 

Johnson, S.L., & McMurrich, S. (2006, Fall). “Life events and juvenile bipolar disorder: Conceptual issues and early findings.” Deviant Psychopathology, 1169-1179.

 

Jolin, E.M., Weller, E.B., & Weller, R.A. (2007, April). “The public health aspects of bipolar disorder in children and adolescents.” Current Psychiatry Reports, 106-113.

 

Kerr, N.J. (1987-1988). “Signs and symptoms of depression and principles of nursing intervention.” Perspectives on Psychiatric Care, 48-63.

 

Lloyd, T., Kennedy, N., Fearon, P., Kirkbride, J., et al. (2005, February). “Incidence of bipolar affective disorder in three UK cities: results from the AESOP study.” British Journal of Psychiatry, 126-131.

 

Madaan, V., & Chang, K.D. (2007, August). “Pharmacotherapeutic strategies for pediatric bipolar disorder.” Expert Opinion on Pharmacotherapy, 1801-1819.

 

Maletzky, B.M. (1979, July). “Enhancing the efficacy of lithium treatment by combined use with diuretics and low sodium diets: a preliminary report.” Journal of Clinical Psychiatry, 317-322.

 

McColm, R., Brown, J., & Anderson, J. (2006, January). “Nursing interventions for the management of patients with mania.” Nursing Standard, 46-50.

 

Miller, K. (2006, August). “Bipolar disorder: etiology, diagnosis, and management.” Journal of the American Academy of Nurse Practitioners, 368-373.

 

Naylor, G.J., & Smith, A.H. (1981, May). “Vanadium: a possible aetiological factor in manic depressive illness.” Psychological Medicine, 249-256.

 

Noaghiul, S., & Hibbeln, J.R. (2003, December). “Cross-national comparisons of seafood consumption and rates of bipolar disorders.” American Journal of Psychiatry, 2222-2227.

 

Olson, P.M., & Pacheco, M.R. (2005, June). “Bipolar disorder in school-age children.” Journal of School Nursing, 152-157.

 

Parker, G., Gibson, N.A., Brotchie, H., Heruc, G., et al. (2006, October). “Omega-3 fatty acids and mood disorders.” American Journal of Psychiatry, 1842.

 

Scheffer, R.E. (2007, October). “Concurrent ADHD and bipolar disorder.” Current Psychiatry Reports, 415-419.

 

Sempels, C., & Sienaert, P. (2007). “The role of omega-3 fatty acids in the treatment of bipolar disorders: the current situation.” Tidschrift Voor Psychiatrie, 639-647.

 

Serene, J.A., Ashtari, M., Szeszko, P.R., & Kumra, S. (2007, March). “Neuroimaging studies of children with serious emotional disturbances: a selective review.” Canadian Journal of Psychiatry, 135-145.

 

Shaldubina, A., Stahl, Z., Furszpan, M., Regenold, W.T., et al. (2006, April). “Inositol deficiency diet and lithium effects.” Bipolar Disorder, 152-159.

 

Soutullo, C.A., Chang, K.D., Diez-Suarez, A., Figueroa-Quintana, A., et al. (2005, December). “Bipolar disorder in children and adolescents: international perspective on epidemiology and phenomenology.” Bipolar Disorder, 497-506.

 

Stensland, M.D., Jacobson, J.G., & Nyhuis, A. (2007, August). “Service utilization and associated direct costs for bipolar disorder in 2004: an analysis in managed care.” Journal of Affective Disorders, 187-193.

 

Strawn, J.R., & Delbello, M.P. (2008, February). “Olanzapine for the treatment of bipolar disorder in children and adolescents.” Expert Opinion on Pharmacotherapy, 467-474.

 

Thase, M.E. (2006, Fall). “Bipolar depression: diagnostic and treatment considerations.” Deviant Psychopathology, 1213-1230.

 

Townsend, L.D., Demeter, C.A., Wilson, M., & Findling, R.L. (2007, February). “Update on pediatric bipolar disorder.” Current Psychiatry Reports, 529-534.