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- Title
ADHD as predictive factor of poor outcome in pediatric bipolar disorder.
- Authors
Carucci, Sara; Atzori, Paola; Balia, Carla; Danjou, Fabrice; Zuddas, Alessandro
- Abstract
Introduction: Recognition that bipolar disorder (BD) can occur during adolescence and probably during childhood is currently well established, but its phenomenology and clinical prevalence during development continue to be controversial [1]. BD meeting full DSM-IV criteria is very rare in pre-pubertal children and debate on classification of severe non-episodic irritability as BD-NOS or Severe Mood Dysregulation continue to be a challenging and controversial argument [2]. Several investigations are under way in order to define whether the strong association with externalizing disorders such as comorbidity with ADHD, the family history as well as the longitudinal course of the disorder may be appropriate criteria to define a specific phenotype. A better understanding of the clinical presentation and longitudinal outcome of pediatric bipolar disorder is essential for improving early diagnosis and for advancing appropriate treatment strategies and neurobiological research. Objectives: The aim of the study was to describe the demographic and clinical characteristics of children and adolescents with bipolar disorder I (BP-I), II (BP-II) and not otherwise specified (BP-NOS) and to explore the possible influence of ADHD comorbidity on drug response and clinical outcome 24 months after the initial hospitalization within the three groups. Methods: The medical charts of 71 inpatients, aged 6–18 years, meeting DSM-IV diagnostic criteria for BP-I (n = 45), BP-II (n = 10) and BP-NOS (n = 16) were retrospectively reviewed. Data regarding clinical presentation, previous psychiatric and medical illnesses, psychiatric comorbidity and parental psychopathology were obtained during the admission. The diagnosis was established based on the results of the semi-structured interview K-SADS-PL and on the clinical assessment by a child and adolescent neuropsychiatrist. The patients were followed up for 24 months and the longitudinal course of the disorder was assessed at baseline, 6, 12 and 24 months by the children global assessment scale (C-GAS). Data analysis: Categorical comparisons were based on contingency tables (v2); continuous variables were compared by one-way ANOVA. Repeated measures ANOVA was performed for C-GAS scores at baseline, 6-, 12- and 24-month follow-up. Statistical significance required two-tailed p B 0.05. Results: BP-NOS significantly differed from BP-I in age of onset (11.2 ± 3.3 years vs. 15.2 ± 2; p\0.001), in lifetime rates of comorbid diagnosis (BP-NOS had higher rates of ADHD and ODD; p = 0.001 and = 0.05, respectively) and from both BP-I and II in the types of mood symptoms that lead to the admission (BP-I had more severe manic symptoms and higher rates of psychosis, p\0.005; BP-II had more severe depressive symptoms, p\0.05). There were no significant differences among the three groups in IQ, family history and polarity of the first affective episode (mainly presenting with mixed episodes). Most of BP-II and BP-NOS have been chronically treated with mood stabilizers while more than the 50% of BP-I needed to be treated with a combined treatment of mood stabilizers and antipsychotics (p = 0.04). Despite a similar severity of illness between BP-NOS and BP-II at baseline, and a relatively comparable pharmacologic approach within the three groups, the longitudinal outcome, assessed by C-GAS, showed a poorer functional outcome for BP-NOS after 24 months (p = 0.010), confirming diagnosis to be a predictor for the longitudinal outcome. Between subjects effects calculated with repeated measures ANOVA revealed IQ and sex to affect CGAS in the way that patients with lower IQ (p = 0.006) and female sex (p = 0.026) were more impaired. Finally, ADHD appeared as a predictor of a poorer outcome within the sample of all bipolar patients presenting with normal IQ (p = 0.003). Conclusion: These findings validate the existence of different subtypes of pediatric bipolar disorder and confirm that BD-NOS present with a more complex clinical and biological heterogeneity compared to BD-I and BD-II. Subjects with an earlier onset and ADHD comorbidity tended in fact to present a worse outcome with a poorer response to treatments and higher functional impairment after 2 years. A better definition of the disorder and a better understanding of its features in the different populations appear to have significant treatment implications. Innovative therapeutic approaches are urgently required to address the clinical needs of these severe impaired patients and improve their clinical outcome and global functioning.
- Publication
European Child & Adolescent Psychiatry, 2010, Vol 19, pS83
- ISSN
1018-8827
- Publication type
Article
- DOI
10.1007/s00787-010-0117-5