The findings are old hat. It's long been known that manic-depression most often begins around the age of 20, give or take a few years. Onset in later life is less common while earlier onset is very unusual.
The main graph could have been lifted from any psychiatry textbooks of the last century:
The red bars are the data. Ignore the black line, that just shows an imaginary 'even' distribution over the lifespan.
Why am I blogging about these remarkably unremarkable results? Because they undermines the theory, popular in certain quarters but highly controversial, that 'child bipolar' or 'pediatric bipolar' is a major health problem.
The study confirmed that early-onset bipolar I does exist, but just 5% of the bipolar I patients had an onset before the age of 15. Assuming a lifetime prevalence of 1% for bipolar I disorder, which is about right, that makes about 0.05%, 1 in 2000 kids, about the same prevalence as Down's Syndrome. Even that's an overestimate, though, because this sample was enriched for early-onset cases: some of the participating clinics were child and adolescent only.
There's a few caveats. This was a retrospective study, that took adults diagnosed bipolar, and asked when their symptoms first appeared. It's possible that early onset cases were under-sampled, if they were less likely to survive to adulthood, or get treated. The generally milder bipolar II might also be different from the bipolar I studied here. But in general, these numbers support the traditional view that childhood bipolar is just not very prevalent.
Baldessarini, R., Tondo, L., Vázquez, G., Undurraga, J., Bolzani, L., Yildiz, A., Khalsa, H., Lai, M., Lepri, B., Lolich, M., Maffei, P., Salvatore, P., Faedda, G., Vieta, E., and; Tohen, M. (2012). Age at onset versus family history and clinical outcomes in 1,665 international bipolar-I disorder patients World Psychiatry, 11 (1), 40-46 DOI: 10.1016/j.wpsyc.2012.01.006
11 comments:
Your caveats are very important. I think it's very important to point out that the long term memory of someone on psychiatric medications for Bipolar 1 may be impaired.
As someone with Bipolar 2, I can recall cyclothymic issues as far back as at least age 10. I can also recall explosive temper issues and extreme sadness at preschool age and primary school age (that now as a parent, do not seem like normal developmental emotional expressions; and they certainly were not like my peers).
Having a patient recall symptoms is not so reliable as having a family member be an outside informed reporter of medical history.
I'll agree childhood onset is still rare. But the outliers are still there. The "problem" is in how to effectively help the child and family. Not over-treat, but also not let the oh-so plastic brain get wired into unhealthy "bipolar patterns".
You see, I cannot help but wonder how my life may have turned out if I had been diagnosed at say, 13? or even 17? During some of my most depressed episodes of adolescence.
If one has an an operating theory that something in puberty triggers bipolar I, one would expect the choice of a 11-15 bin to overstate pre-puberty v. post-puberty cases, with the contrentration within the bin being at the high end and associated within the bin with other signs of advanced development (e.g. stature gain or onset of menses age).
Many believe that the epidemic of childhood bipolar disorder in the USA is due to health insurance reimbursement and medico-legal issues.
It is much harder to support the need for high levels of services including prolonged hospitalization for children with externalizing disorders (ODD, CD) whereas if the primary diagnosis is bipolar disorder, insurance companies generally do not raise problems. Additionally, in cases of symptoms refractory to psychological interventions, physicians are medio-legally more justified resorting to using low-doses of antipsychotics for treatment of a child with a diagnosis of bipolar disorder compared to externalizing disorders.
These two issues explain why the spike in childhood bipolar diagnoses has not occurred Canada, where we have public health care and our society is less litigious.
Zigs: Interesting. That makes a lot of sense.
Andrew: Yes, presumably people are clustered at the top of the 11-15 bin.
Food for thought from Laura Delano's speach at the 2012 APA meeting protest:
"(...)It is an honor to be able to call myself a psychiatric survivor, especially one representing my generation— the medicated generation, a generation in which facing the emotional upheaval that comes with hitting puberty has meant being diagnosed with bipolar disorder, ADHD, depression, anxiety, or schizophrenia and subsequently medicated with brightly colored capsules and bitter-tasting tablets.(...)"
http://www.madinamerica.com/2012/05/on-recovering-from-psychiatric-labels-and-psychotropic-medications-an-occupy-apa-manifesto/
Dineen,
///Not over-treat, but also not let the oh-so plastic brain get wired into unhealthy "bipolar patterns".///
I am afraid that psychiatric drugs have never been proven to be curative in the sense of promoting healthy wiring of brains.
Their side-effect are very serious
and even a threat to life expectancy.
That gifted clever boy,
twelve-year-old Ke’onte Cook Testified in US Senate Hearing.He desserve to be heard about the effect of medication-although his carers might have found him calmer and easier to deal with:
http://d1078319.site.myhosting.com/?p=3079
PS: Of course I do not know but you might have suffered a more difficult childhood than your children and classmates.
this study is important for physicians who make psychiatric diagnosis in children. If 95% of adults with bipolar only began experiencing it in later adolescence or adulthood, then it must be close to impossible to diagnosis it in children younger than 15.
Julia,
You have made a strong point;
Thanks.
Plus, many women are diagnosed bipolar when they suffer from PMTS and hormones is the cure.
I never studied it but I would think some men will also suffer from mood disorder due to sexual hormones fluctuating blood concentration...
I would be cautious in using this study alone to suggest that childhood onset bipolar is not a major health issue.
Firstly, your caveats are indeed important. Recall bias could have a strong effect on these results. Previous studies have used life charting methods to reduce this bias, and it isn't clear if it was used in this study. Further, this study only assessed bipolar I via strict DSM-IV criteria. The phenomenology of childhood bipolar disorder appears to be somewhat different than that of adults, with more rapid cycling, perhaps more children receiving the diagnosis of Bipolar II or NOS -- and while there is valid concern about child with other externalizing disorders being misdiagnosed as bipolar, longitudinal studies do indicate that a large number of children diagnosed with BP II or NOS have similar syndromes over time. This study needs to be reconciled with other studies assessing age of onset in adults -- for example the STEP-BD study looked at age of onset for any bipolar disorder in almost 1000 adults (with good methodology) and found that over 25% had age of onset before age 13 (Perlis et al 2004)
Probably most importantly, though, those with childhood onset bipolar seem to have a more severe illness course, and children and adolescents with Bipolar II or Bipolar NOS have repeatedly been shown to have very similar levels of functional and psychosocial impairment as those with Bipolar I. Initial alarm over child and adolescent Bipolar disorder may have been a little overblown, but we need to keep it on our radar as a major health problem, in particular because we don't really know yet how to best treat it when it occurs at these ages.
really appreciated!
thank you……
I'm BP I. I was diagnosed at 37 years old. In retrospect I suffered with childhood BP. I recall the rapid cycling and manic feelings. My grandmother would often say that there was something wrong, that I would get too high. As I got into my teens she said to me that she didn't hold against me the things that I did because although it was me, it just wasn't me.
I was diagnosed with Grave's disease at 18 and all my behavior prior and since was attributed to the hypermania. Post-natal depression resulted in a manic episodes which I thought were due to my overwhelming relief at not being depressed.
It wasn't until I sought day treatment for alcohol abuse at 37 that I was finally diagnosed. I was put on antidepressants and started rapid cycling. I was in disbelief. I didn't know much about bipolar disorder and what I did know I didn't think possible applied to me. I bought a basic, read up online and slowly came to the realization that I am the person described. I ran symptom lists by friends and family and it was like a light went on.
I often wish my diagnosis had been made earlier. I'm so sad for the life I could have had. I pray that childhood BP is recognized and more lives aren't lost. I'm alive, but I still lost mine.
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