Severity of bipolarity in hospitalized manic adolescents with history of stimulant or antidepressant treatment

doi:10.1016/S0165-0327(01)00336-6

Journal of Affective Disorders

Volume 70, Issue 3, August 2002, Pages 323-327

https://doi.org/10.1016/S0165-0327(01)00336-6 Get rights and content

Abstract

Background: Childhood bipolarity (BP) and ADHD frequently co-occur, these children often receive stimulants. Method: We retrospectively evaluated 80 adolescents hospitalized with BP, manic or mixed, assessed severity of hospital course, and compared groups according to current/past stimulant or antidepressant treatment. Results: Lifetime ADHD rate was 49%; 35% of patients had exposure to stimulants and 44% to antidepressants. Stimulant-exposed patients were younger than non-exposed (mean±S.D.=13.7±2 vs. 15.1±2 years, Z=−3.1, P=0.002). Only stimulant exposure was associated with worse hospitalization course (MANCOVA, Wilks’ Lambda=0.87, F=3.4; df=70; P=0.02). Conclusion: Stimulant-exposed BP-adolescents may have more severe illness course not fully explained by ADHD comorbidity. Limitations: Retrospective methodology and lack of structured interviewing make it difficult to quantify exposure to stimulants and antidepressants.

Section snippets

Background

Juvenile mania has been recognized for years, but there is no consensus on its prevalence or the significance of co-occurring attention deficit/hyperactivity disorder (ADHD) (Carlson, 1998). Bipolar disorder (BP) and ADHD frequently co-occur in children, adolescents, and adults (Biederman et al., 1996; West et al., 1995; Geller and Luby, 1997). Family genetic studies show that ADHD co-occurring with BP is distinct from other forms of ADHD and may be related to childhood-onset BP (Faraone et

Method

In retrospective chart review we identified 80 adolescents consecutively hospitalized at Children’s Hospital Medical Center Adolescent Psychiatry Unit over a period of two years with a clinical discharge diagnosis of DSM-IV bipolar disorder (manic or mixed episode). On those adolescents hospitalized more than once during the period of the study, we only included in the analysis data on their first hospitalization. We recorded demographic and clinical characteristics, including co-ocurring

Results

We identified 80 adolescents (50 male, 30 female, age±S.D.=14.6±1.9 years old, range 10–19) with a discharge diagnosis of DSM-IV BP (manic episode: N=53, 63%. mixed episode: N=27, 34%). Nine (11%) patients had a diagnosis of rapid cycling and 13 (16%) had psychotic features. Their demographic and clinical characteristics are summarized in Table 1. Their ethnic background was Caucasian 78%, African–American 18%, and other 5%. The (mean±S.D.) hospital length of stay was 9±7 days (range: 2–40),

Conclusion

Adolescents with BP hospitalized for acute manic or mixed episode had a high rate of lifetime ADHD (49%). History of stimulant treatment (but not a history of ADHD diagnosis, antidepressant treatment, mixed or manic episode) was associated with a more severe overall course of acute illness during hospitalization (as measured by hospital stay, need for PRN medication, and S&R orders to control agitation). This study has important methodological limitations than must be considered, such as the

Acknowledgements

The authors would like to acknowledge the generous support of the Theodore and Vada Stanley Foundation and the Stanley Scholars Program (Ms. Ochsner)

References (21)

J. Biederman et al.
Attention-deficit hyperactivity disorder and juvenile mania: an overlooked comorbidity?
J. Am. Acad. Child Adolesc. Psychiatry
(1996)
K.N. Botteron et al.
Pharmacologic treatment of childhood and adolescent mania
Child Adolesc. Clin. N. Am.
(1995)
D.P. Cantwell
Attention deficit disorder: a review of the past 10 years
J. Am. Acad. Child Adolesc. Psychiatry
(1996)
G.A. Carlson
Mania and ADHD: comorbidity or confusion
J. Affect. Disord.
(1998)
S.V. Faraone et al.
Attention-deficit hyperactivity disorder with bipolar disorder: a familial subtype?
J. Am. Acad. Child Adolesc. Psychiatry
(1997)
B. Geller et al.
Rate and predictors of prepubertal bipolarity during follow-up of 6- to 12-year old depressed children
J. Am. Acad. Child Adolesc. Psychiatry
(1994)
B. Geller et al.
Child and adolescent bipolar disorder: a review of the past 10 years
J. Am. Acad. Child Adolesc. Psychiatry
(1997)
J.E. Max et al.
Antimanic effectiveness of dextroamphetamine in a brain-injured adolescent
J. Am. Acad. Child Adolesc. Psychiatry
(1995)
M. Strober et al.
A family study of bipolar I disorder in adolescence. Early onset of symptoms linked to increased familial loading and lithium resistance
J. Affect. Disord.
(1988)
M. Strober et al.
Early childhood attention deficit hyperactivity disorder predicts poorer response to acute lithium therapy in adolescent mania
J. Affect. Disord.
(1998)

There are more references available in the full text version of this article.

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Citation Excerpt :
In those with ADHD in concert with prominent bipolar symptoms, most authorities would recommend mood stabilization prior to the use of stimulants. The potential role of stimulants in triggering a manic episode is controversial, as discussed in detail by Soutullo et al (2002) and Goldsmith et al (2011). The latter article concludes “There is no clear evidence that stimulants or SSRIs accelerate the natural course of BD development in overall samples, but in individual cases prescribers should proceed cautiously when using these agents in youth already at risk for developing BD, such as those with ADHD and mood dysregulation, a history of prior AIM (antidepressant-induced mania), a history of psychosis, or a family history of BD.”
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Brief reportSeverity of bipolarity in hospitalized manic adolescents with history of stimulant or antidepressant treatment

Abstract

Section snippets

Background

Method

Results

Conclusion

Acknowledgements

J. Am. Acad. Child Adolesc. Psychiatry

Child Adolesc. Clin. N. Am.

J. Am. Acad. Child Adolesc. Psychiatry

J. Affect. Disord.

J. Am. Acad. Child Adolesc. Psychiatry

J. Am. Acad. Child Adolesc. Psychiatry

J. Am. Acad. Child Adolesc. Psychiatry

J. Am. Acad. Child Adolesc. Psychiatry

J. Affect. Disord.

J. Affect. Disord.

Brief report
Severity of bipolarity in hospitalized manic adolescents with history of stimulant or antidepressant treatment