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Background: Early-onset psychosis is a symptomatically nonspecific and heterogeneous entity composed of several diagnoses. This study examined the dimensional structure of symptoms and the temporal stability of this structure during a 6-month follow-up.
Method: A principal component factor analysis of the Positive and Negative Syndrome Scale was conducted at baseline, 4 weeks, and 6 months in a sample of 99 first-episode psychotic patients (mean age = 15.5 years).
Results: The factor analysis produced a 5-dimension solution (Positive, Negative, Depression, Cognitive, Hostility) that explained 62.4% of the variance at baseline, 63.4% at 4 weeks, and 65.1% at 6 months. Negative dimension was the most consistent and stable over time and was predominant at baseline (23.9%) and at 4 weeks (25.7%). Depression was predominant at 6 months (31.1%).
Conclusions: There is a stable 5-dimension structure of symptoms in early-onset psychosis with varying predominance of symptoms over time. Negative symptoms are a core feature of psychosis and are thus important diagnostic criteria.
J Clin Psychiatry 2010;71(3):327-337
Submitted: November 4, 2008; accepted June 3, 2009.
Corresponding author: Marta Rapado-Castro, PhD, Adolescent Unit, Department of Psychiatry, Hospital General Universitario Gregorio Mara×±ón, C/ Ibiza 43, 28009 Madrid, Spain ([email protected]).
The presentation of bipolar disorder in children and adolescents may vary from its presentation in adults. Rage, irritability, and long episodes are common manifestations of mania in young people with bipolar disorder. Frequent comorbid disorders in young patients include ADHD and anxiety disorders. Prodromal and subsyndromal states of bipolar disorder, such as bipolar disorder NOS, present opportunities for early intervention and prevention. Early recognition and intervention are crucial, because untreated pediatric bipolar disorder becomes chronic, has a high incidence of relapse, and has a poor prognosis.
Letter to the Editor
Untreated early-onset bipolar disorder is associated with higher rates of rapid cycling, more comorbidity, and more severe mania and depression than adult-onset bipolar disorder. Correctly diagnosing bipolar disorder early in its course can prevent exposing a young patient to treatments that may exacerbate or advance the progression of the disorder. Appropriate pharmacologic and psychosocial interventions are necessary in the acute treatment of pediatric bipolar disorder.
Bipolar disorder is an increasingly common diagnosis given to children and adolescents. Most studies of lithium, anticonvulsants, and atypical antipsychotics have been conducted in adult populations, but new data are providing information on the safety and tolerability of these medications for treating children and adolescents. Although generally well tolerated, psychotropic agents have different side effect profiles that should be considered when planning treatment regimens for pediatric patients. Additional controlled and comparative trials are needed on the safety and tolerability of these medications in young patients, especially for long-term maintenance treatment.
Pediatric-onset bipolar disorder is common but often difficult to diagnose in younger patients. Clinicians should be sure to establish the presence of a full manic episode to make the diagnosis of bipolar I disorder. Because adult criteria are used for children and adolescents, clinicians also should be aware of developmental norms that can help to make an accurate diagnosis. Bipolar disorder NOS and other disorders in children and adolescents may be prodromal states for bipolar disorder, especially in the presence of a positive family history.
Objective: To study the relationship between negative life events and demographic and clinical variables in youth with bipolar I disorder, bipolar II disorder, and bipolar disorder not otherwise specified (NOS), as well as to compare the rates of life events in youth with bipolar disorder, depressive and/or anxiety disorders (DEP-ANX), and healthy controls.
Method: Subjects included 446 youth, aged 7 to 17 years, meeting DSM-IV criteria for bipolar I, bipolar II, or an operationalized definition of bipolar disorder NOS, and were enrolled in the Course and Outcome of Bipolar Illness in Youth study. Subjects completed the Life Events Checklist. Sixty-five DEP-ANX and 65 healthy youth were obtained from previous studies using similar methodology. The study was conducted from October 2000 to July 2006.
Results: Older age, lower socioeconomic status, living with nonintact family, non-Caucasian race, anxiety, and disruptive disorders were associated with greater number of total negative life events. Specifically, increased independent, dependent, and uncertain negative life events were associated with lower socioeconomic status, nonintact family, and comorbid disruptive disorders. Increased independent negative life events were additionally associated with non-Caucasian race and comorbid anxiety disorders. Increased dependent and uncertain negative life events were also associated with older age. DEP-ANX youth reported a similar rate of negative life events as bipolar youth, and both groups had more negative life events than the healthy controls. Bipolar youth reported fewer total and dependent positive life events compared to DEP-ANX and healthy youths.
Conclusions: Similar to DEP-ANX youth, bipolar youth are exposed to excessive negative independent and dependent life events, which may have implications in the long-term outcome and negative consequences associated with this disorder.
Submitted: December 12, 2008; accepted April 24, 2009.
Corresponding author: Soledad Romero, MD, Hospital Clinic University of Barcelona, Institute Clinic of Neuroscience, Villarroel 170, Barcelona, Catalonia 08036, Spain ([email protected]).
From our regular book review column.
Clinical Manual of Child and Adolescent PsychopharmacologyClinical Manual of Child and Adolescent Psychopharmacology
Bipolar disorder is an increasingly common diagnosis in children and adolescents. Although psychosocial interventions are important for these young patients, treatment guidelines presently focus on pharmacologic therapy in the acute treatment of pediatric bipolar I disorder. Placebo-controlled studies have been conducted with lithium, anticonvulsants, and atypical antipsychotics, but more research is needed, especially in areas other than acute manic and mixed episodes. Additional studies are needed to determine the safest and most effective agents for treating children and adolescents with bipolar disorder.
Objective: This study examines the number and type of medical comorbidities among youth diagnosed with bipolar disorder.
Method: This is a retrospective data analysis using the 2000-2001 Thomson Medstat MarketScan medical claims and administrative files. The population included a national sample of youth (ages 6-18 years) from privately insured families within the United States. Number of chronic medical conditions and type of medical comorbidity were analyzed in ICD-10-diagnosed youth with bipolar disorder (N = 832) and other types of psychiatric disorders (N = 21,493) using The Johns Hopkins Adjusted Clinical Groups Case Mix System, Version 8.0.
Results: Thirty-six percent of youth with bipolar disorder had 2 or more chronic health conditions versus 8% of youth with other psychiatric diagnoses. The following categories of medical conditions were significantly more prevalent in youth diagnosed with bipolar disorder: cardiology, gastrointestinal/hepatic, neurologic, musculoskeletal, female reproductive, and respiratory. Toxic effects and adverse events were also higher in youth with bipolar disorder, compared to youth with other psychiatric disorders.
Conclusions: Youth with bipolar disorder experience higher rates of several medical illnesses compared to youth with other psychiatric diagnoses. Several factors may explain this phenomenon, including worse medication side effects, unhealthy lifestyle behaviors, poorer access to health care services, socioeconomic status, and biologic susceptibility. Moreover, a diagnosis of bipolar disorder may reflect more frequent health care utilization and therefore more opportunities for additional medical diagnoses. Further understanding regarding reasons for these relatively high rates of comorbidity among youth diagnosed with bipolar disorder may be helpful in improving overall health and quality of life during the early stages/onset of this disorder.
Submitted: October 25, 2008; accepted March 10, 2009.
Online ahead of print: September 8, 2009.
Corresponding author: Sara E. Evans-Lacko, PhD, Health Services Research Department, Institute of Psychiatry, King's College London, De Crespigny Park, London SE5 8AF, United Kingdom ([email protected]).
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