TORONTO — Many children with bipolar disorder experience a lengthy prodromal phase of clinically significant symptoms before their first manic episode; in almost 70% of these children, the prodrome begins with a drop in school functioning, often accompanied by racing thoughts, irritability, and anger, and can last for almost 1 year.
Recognizing such a prodrome could help facilitate early intervention for children at risk of developing bipolar disorder, Dr. Christoph Correll reported at the joint annual meeting of the American Academy of Child and Adolescent Psychiatry and the Canadian Academy of Child and Adolescent Psychiatry.
“The sufficient duration and severity of this prodrome enables the development of early identification and prevention programs,” wrote Dr. Correll, a psychiatrist at the Zucker Hillside Hospital, Glen Oaks, N.Y. However, “prospective studies are required to validate these findings and to test effective interventions.”
Dr. Correll characterized the onset of bipolar disorder in 51 patients by interviewing the patients and/or their parents with his newly created Bipolar Prodrome Symptoms Scale-Retrospective Version. The questionnaire asks parents and patients to rate 39 putatively prodromal symptoms that can emerge before a syndromal manic or hypomanic episode.
The scale—an in-person structured interview with patient or parent alone—takes between 1 and 1.5 hours to complete. It was developed based on DSM-IV criteria for major depressive disorder and bipolar disorder, a review of the literature, input from experts in the areas of schizophrenia prodrome and bipolar disorder, and open questioning of young patients and their caregivers.
Dr. Correll also drew the symptoms that the scale assesses from several retrospective studies that have identified some possibly prodromal traits, including depressed mood or hopelessness, hyperactivity, mood swings, increased or decreased energy, irritability or anger dyscontrol, argumentativeness, decreased sleep, crying spells, inappropriate behaviors, and overtalkativeness.
The patients' mean age was 16 years; the mean age at first manic episode was 13 years. The patients experienced a mean of 13 of the prodromal symptoms, which preceded the first full manic episode by nearly 1 year.
In more than half of the patients, the most commonly reported symptoms that were at least moderately severe were a drop in school functioning, irritability or anger, racing thoughts, mood swings, inattention, depressed mood, and anger outbursts or tantrums. At least moderately severe symptoms of increased energy, psychomotor agitation, overtalkativeness, and social isolation occurred in more than 40% of patients.
The most common presenting symptoms were a drop in school functioning, mood swings, depressed mood, irritability or anger, social isolation, and racing thoughts. About one in five patients reported presenting symptoms of oppositionality, anhedonia, being overly cheerful, psychomotor agitation, or inattention.
The lag between first manic episode and bipolar disorder diagnosis was about 20 months, but the lag between the onset of prodromal symptoms and diagnosis was about twice that long—a mean of 41 months. In most patients (59%), the prodromal onset was slow and marked by gradual deterioration; 29% of patients experienced a slow onset with quick deterioration, while only 12% had a rapid onset of illness.
The newly developed scale will be useful not only in assessing a possible prodrome, but in research as well, Dr. Correll said in an interview. “It can be used in future studies to determine different patterns of symptom onset and contributing factors to symptom onset, as well as to identify characteristics that may define a person who may be at ultrahigh risk for the development of bipolar disorder.”
He is also working on a prospective version of the scale, which he hopes will be a valuable tool for predicting conversion to bipolar disorder in patients considered to be at risk for the disorder.
In most patients (59%), the prodromal onset was slow and marked by gradual deterioration. DR. CORRELL