A 24-year-old male who was a family friend of a pediatrician, was talking with her at a social event after not seeing each other for several months. He told her that he had recently been diagnosed with bipolar disorder. “It’s a real struggle. I want to show up for work and do my work well. I try very hard to do that, but when I come home I still have to deal with the rest of life,” he said. He went on, “The new medicine seems to be working better. I still feel flat, but its soooo much better than the depression. Anything is better than that. But I miss some of the wild-side of me a bit. Being a little louder, life-of-the-party guy. You know, you really haven’t totally experienced life if you haven’t been manic. It must be what people do when they trip acid or other drugs. There’s just this whole other side of life.” “But I would never trade that for having the depression. There are no words for that,” he emphasized and shook his head. “I worry about my family and how this affects them. That’s why I keep taking my medicine even when things are bad. I have to take care of me to help them,” he related.
The pediatrician was thinking about the depressive episodes she had helped support him and his family with since he was about 15 years old. She had missed the mania though. The loud get together with friends where the cops were called for disturbing the peace, doing woodworking in the garage until early hours, times where he always seemed to be moving. It fit now. She offered her continued support and affirmed that he seemed to be making good choices about how he was dealing with his illness.
Bipolar disorder (BD) is a chronic, recurrent, affective disorder with fluctuations in energy and mood. “Bipolar disorder, previously known as manic depressive illness, is a severe chronic mood disorder characterized by episodes [note not just one instance] of mania, hypomania, and alternating or intertwining episodes of depression.” Affective disorders are classified based on their severity and extent, from unipolar to BDII to BDI. “Individuals with unipolar disorder present with depressive episodes only, and those with bipolar II or I disorder show increasingly pronounced episodes of mood elevation.”
Hypomania or mania episodes are elevated mood states with “…increased motor drive that are finite in time and differ in severity and length.” Patients with an acute mania episode present with psychotic symptoms which may be mood congruent (e.g. grandiosity) or mood incongruent (e.g. persecution). Patients with depression may have hypomania symptoms, therefore it is important to try to elicit more subtle symptoms by history.
BD occurs worldwide. BDII affects more women and BDI affects men and women equally. It often presents in adolescence and young adulthood, but can occur earlier or later. Up to 60% of individuals will present before age 21.
There is a large difference in the prevalence rates based upon what age groups are included and sex. More than 1% is usually the prevalence noted in many studies, but the age weighted prevalence of bipolar disorders in the 7-21 year old population is ~ 2.1%. Families with mood disorders, particularly BD, are at a higher risk of BD. Differential diagnosis commonly includes attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder, disruptive mood dysregulation disorder for adolescents but also anxiety, schizophrenia, substance abuse, personality disorders and of course major depressive disorder. Co-morbidities are not uncommon particularly ADHD.
Adolescents may be more difficult to diagnose because they have more mixed episodes or rapidly cycling episodes. Their hypomania or mania is often short-lived. They also may not be able to accurately report and the symptoms commonly overlap as they may be “just irritable” or have “temper outbursts” and be “difficult to communicate with.” You can have both elation and irritability during their severe episodes.
People with BD can have cognitive and functional impairments that can lead to high rates of medical and psychiatric problems including death by suicide (20 times higher than the general population). BD is the 4th leading cause of disability in individuals 10-24 years old.
Second generation antipsychotics are effective and youth are more sensitive to metabolic side effects. Mood stabilizers are less effective in youth than in the adult population. Therapy is also helpful for the patient and family.
Questions for Further Discussion
1. What history question can be asked to try to elicit a history of hypomania or mania?
2. What should be included in a mental health safety plan? For a review, click here.
- Disease: Bipolar Disorder | Mood Disorders
- Symptom/Presentation: Behavior Problems | Depression
- Specialty: Adolescent Medicine | Psychiatry and Psychology
- Age: Young Adult
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Bipolar Disorder and Mood Disorder.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Grande I, Berk M, Birmaher B, Vieta E. Bipolar disorder. Lancet. 2016 Apr 9;387(10027):1561-72.
Goldstein BI, Birmaher B, Carlson GA, DelBello MP, Findling RL, Fristad M, et.al. The International Society for Bipolar Disorders Task Force report on pediatric bipolar disorder: Knowledge to date and directions for future research. Bipolar Disorders. 2017:19;524-543.
Stepanova E, Findling RL. Psychopharmacology of Bipolar Disorders in Children and Adolescents. Pediatr Clin North Am. 2017 Dec;64(6):1209-1222.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa