Guillermo Perez Algorta

Suicidality in pediatric bipolar disorder: predictor or outcome of family processes and mixed mood presentation?

OBJECTIVE Pediatric bipolar disorder (PBD) involves a potent combination of mood dysregulation and interpersonal processes, placing these youth at significantly greater risk of suicide. We examined the relationship between suicidal behavior, mood symptom presentation, family functioning, and quality of life (QoL) in youth with PBD. METHODS Participants were 138 youths aged 5-18 years presenting to outpatient clinics with DSM-IV diagnoses of bipolar I disorder (n=27), bipolar II disorder (n=18), cyclothymic disorder (n=48), and bipolar disorder not otherwise specified (n=45). RESULTS Twenty PBD patients had lifetime suicide attempts, 63 had past or current suicide ideation, and 55 were free of suicide ideation and attempts. Attempters were older than nonattempters. Suicide ideation and attempts were linked to higher depressive symptoms, and rates were even higher in youths meeting criteria for the mixed specifier proposed for DSM-5. Both suicide ideation and attempts were associated with lower youth QoL and poorer family functioning. Parent effects (with suicidality treated as outcome) and child effects (where suicide was the predictor of poor family functioning) showed equally strong evidence in regression models, even after adjusting for demographics. CONCLUSIONS These findings underscore the strong association between mixed features and suicidality in PBD, as well as the association between QoL, family functioning, and suicidality. It is possible that youths are not just a passive recipient of family processes, and their illness may play an active role in disrupting family functioning. Replication with longitudinal data and qualitative methods should investigate both child and parent effect models.

Functional adult outcomes 16 years after childhood diagnosis of Attention-Deficit/Hyperactivity Disorder:MTA results

OBJECTIVE To compare educational, occupational, legal, emotional, substance use disorder, and sexual behavior outcomes in young adults with persistent and desistent attention-deficit/hyperactivity disorder (ADHD) symptoms and a local normative comparison group (LNCG) in the Multimodal Treatment Study of Children with ADHD (MTA). METHOD Data were collected 12, 14, and 16 years postbaseline (mean age 24.7 years at 16 years postbaseline) from 476 participants with ADHD diagnosed at age 7 to 9 years, and 241 age- and sex-matched classmates. Probands were subgrouped on persistence versus desistence of DSM-5 symptom count. Orthogonal comparisons contrasted ADHD versus LNCG and symptom-persistent (50%) versus symptom-desistent (50%) subgroups. Functional outcomes were measured with standardized and demographic instruments. RESULTS Three patterns of functional outcomes emerged. Post-secondary education, times fired/quit a job, current income, receiving public assistance, and risky sexual behavior showed the most common pattern: the LNCG group fared best, symptom-persistent ADHD group worst, and symptom-desistent ADHD group between, with the largest effect sizes between LNCG and symptom-persistent ADHD. In the second pattern, seen with emotional outcomes (emotional lability, neuroticism, anxiety disorder, mood disorder) and substance use outcomes, the LNCG and symptom-desistent ADHD group did not differ, but both fared better than the symptom-persistent ADHD group. In the third pattern, noted with jail time (rare), alcohol use disorder (common), and number of jobs held, group differences were not significant. The ADHD group had 10 deaths compared to one death in the LNCG. CONCLUSION Adult functioning after childhood ADHD varies by domain and is generally worse when ADHD symptoms persist. It is important to identify factors and interventions that promote better functional outcomes.

The bipolar spectrum: myth or reality?

The idea of a “bipolar spectrum” is controversial due to 1) lack of widely accepted definitions, 2) concern that spectrum definitions might subsume cases with non-bipolar disorders, 3) worry that “diagnostic creep” may lead practitioners to overdiagnose bipolar disorder in marginal cases, and 4) worry that more diagnosis of bipolar spectrum may increase aggressive pharmacotherapy. These concerns are weighed against theoretical and empiric evidence converging in support of the bipolar spectrum as having prognostic and prescriptive validity. Practitioners can use inexpensive and practical strategies to incorporate the spectrum concept into their work while minimizing risks of overdiagnosis or unnecessary medication exposure.

The Relationship Between Online Social Networking and Depression: A Systematic Review of Quantitative Studies

Online social networking sites (SNSs) such as Facebook, Twitter, and MySpace are used by billions of people every day to communicate and interact with others. There has been increasing interest in the potential impact of online social networking on wellbeing, with a broadening body of new research into factors associated with both positive and negative mental health outcomes such as depression. This systematic review of empirical studies (n = 30) adds to existing research in this field by examining current quantitative studies focused on the relationship between online social networking and symptoms of depression. The academic databases PsycINFO, Web of Science, CINAHL, MEDLINE, and EMBASE were searched systematically using terms related to online social networking and depression. Reporting quality was critically appraised and the findings discussed with reference to their wider implications. The findings suggest that the relationship between online social networking and symptoms of depression may be complex and associated with multiple psychological, social, behavioral, and individual factors. Furthermore, the impact of online social networking on wellbeing may be both positive and negative, highlighting the need for future research to determine the impact of candidate mediators and moderators underlying these heterogeneous outcomes across evolving networks.

Predictors and moderators in the randomized trial of multifamily psychoeducational psychotherapy for childhood mood disorders.

This study investigated predictors and moderators of mood symptoms in the randomized controlled trial (RCT) of Multi-Family Psychoeducational Psychotherapy (MF-PEP) for childhood mood disorders. Based on predictors and moderators in RCTs of psychosocial interventions for adolescent mood disorders, we hypothesized that childrens greater functional impairment would predict worse outcome, whereas childrens stress/trauma history and parental expressed emotion and psychopathology would moderate outcome. Exploratory analyses examined other demographic, functioning, and diagnostic variables. Logistic regression and linear mixed effects modeling were used in this secondary analysis of the MF-PEP RCT of 165 children, ages 8 to 12, with mood disorders, a majority of whom were male (73%) and White, non-Hispanic (90%). Treatment nonresponse was significantly associated with higher baseline levels of global functioning (i.e., less impairment; Cohens d = 0.51) and lower levels of stress/trauma history (d = 0.56) in children and Cluster B personality disorder symptoms in parents (d = 0.49). Regarding moderators, children with moderately impaired functioning who received MF-PEP had significantly decreased mood symptoms (t = 2.10, d = 0.33) compared with waitlist control. MF-PEP had the strongest effect on severely impaired children (t = 3.03, d = 0.47). Comprehensive assessment of demographic, youth, parent, and familial variables should precede intervention. Treatment of mood disorders in high-functioning youth without stress/trauma histories and with parents with elevated Cluster B symptoms may require extra therapeutic effort, whereas severely impaired children may benefit most from MF-PEP.

An Inexpensive Family Index of Risk for Mood Issues Improves Identification of Pediatric Bipolar Disorder

Family history of mental illness provides important information when evaluating pediatric bipolar disorder (PBD). However, such information is often challenging to gather within clinical settings. This study investigates the feasibility and utility of gathering family history information using an inexpensive method practical for outpatient settings. Families (N=273) completed family history, rating scales, and the Mini-International Neuropsychiatric Interview (Sheehan et al., 1998) and the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children (Kaufman et al., 1997) about youths 5-18 (median=11) years of age presenting to an outpatient clinic. Primary caregivers completed a half-page Family Index of Risk for Mood issues (FIRM). All families completed the FIRM quickly and easily. Most (78%) reported 1+ relatives having a history of mood or substance issues (M=3.7, SD=3.3). A simple sum of familial mood issues discriminated cases with PBD from all other cases (area under receiver operating characteristic [AUROC]=.63, p=.006). FIRM scores were specific to youth mood disorder and not attention-deficit/hyperactivity disorder or disruptive behavior disorder. FIRM scores significantly improved the detection of PBD even controlling for rating scales. No subset of family risk items performed better than the total. Family history information showed clinically meaningful discrimination of PBD. Two different approaches to clinical interpretation showed validity in these clinically realistic data. Inexpensive and clinically practical methods of gathering family history can help to improve the detection of PBD.

Future directions for research on youth with bipolar spectrum disorders

The past 25 years has witnessed significant advances in our knowledge of Bipolar Spectrum Disorders (BPSD) in youth. Cross-sectional and longitudinal studies are clarifying the unique features of its pediatric presentation, including continuities and discontinuities across the spectrum of severity. Advances have been made, both in the pharmacological and psychological management of BPSD in youth. Current investigations may ultimately shed light on new treatment strategies. Future research is anticipated to be influenced by NIMHs Research Domain Criteria (RDoC). With this article, we summarize what is currently known about the basic phenomenology of pediatric BPSD, its clinical course, assessment and treatment, beginning with a summary of the major studies that have shed light on the topic. Next, we present a tally and content review of current research as an indicator of trends for the future. Then, we describe what we believe are important future directions for research. Finally, we conclude with implications for contemporary clinicians and researchers.

Disruptive Mood Dysregulation Disorder and Bipolar Disorder Not Otherwise Specified: Fraternal or Identical Twins?

OBJECTIVE The purpose of this study was to examine similarities and differences between disruptive mood dysregulation disorder (DMDD) and bipolar disorder not otherwise specified (BP-NOS) in baseline sociodemographic and clinical characteristics and 36 month course of irritability in children 6-12.9 years of age. METHODS A total of 140 children with DMDD and 77 children with BP-NOS from the Longitudinal Assessment of Manic Symptoms cohort were assessed at baseline, then reassessed every 6 months for 36 months. RESULTS Groups were similar on most sociodemographic and baseline clinical variables other than most unfiltered (i.e., interviewer-rated regardless of occurrence during a mood episode) Young Mania Rating Scale (YMRS) and parent-reported General Behavior Inventory-10 Item Mania (PGBI-10M) items. Children with DMDD received lower scores on every item (including irritability) except impaired insight; differences were significant except for sexual interest and disruptive-aggressive behavior. Children with DMDD received lower scores on eight of 10 PGBI-10M items, the other two items rated irritability. Youth with DMDD were significantly less likely to have a biological parent with a bipolar diagnosis than were youth with BP-NOS. Children with DMDD were more likely to be male and older than children with BP-NOS, both small effect sizes, but had nearly double the rate of disruptive behavior disorders (large effect). Caregiver ratings of irritability based on the Child and Adolescent Symptom Inventory-4R (CASI-4R) were comparable at baseline; the DMDD group had a small but significantly steeper decline in scores over 36 months relative to the BP-NOS group (b = -0.24, SE = 0.12, 95% CI -0.48 to -0.0004). Trajectories for both groups were fairly stable, in the midrange of possible scores. CONCLUSIONS In a sample selected for elevated symptoms of mania, twice as many children were diagnosed with DMDD than with BP-NOS. Children with DMDD and BP-NOS are similar on most characteristics other than manic symptoms, per se, and parental history of bipolar disorder. Chronic irritability is common in both groups. Comprehensive evaluations are needed to diagnose appropriately. Clinicians should not assume that chronic irritability leads exclusively to a DMDD diagnosis.

Maternal ADHD Symptoms, Personality, and Parenting Stress Differences Between Mothers of Children With ADHD and Mothers of Comparison Children

Objective: Mothers raising a child with ADHD can experience high parenting stress. We evaluated if mothers’ personality traits and own ADHD symptoms could also affect parenting stress. Method: 430 biological mothers from the Multimodal Treatment Study of Children with ADHD (MTA mothers) and 237 of a local normative comparison group (LNCG mothers) were evaluated at baseline. Interactions were tested between mothers’ group and maternal personality/ADHD symptoms related to parenting stress. Results: Compared to LNCG, MTA mothers had higher parenting stress, self-reported ADHD, neuroticism, and lower conscientiousness and agreeableness. When personality and ADHD were evaluated together, ADHD symptoms interacted with mothers’ group: high maternal ADHD was positively associated with parenting stress for LNCG but not MTA mothers. Conclusion: Personality traits or ADHD characteristics do not appear operative for the high parenting stress of mothers of a child with ADHD. However, high maternal ADHD or low conscientiousness are associated with stress levels similar to raising a child with ADHD.

Unfiltered Administration of the YMRS and CDRS-R in a Clinical Sample of Children

The objective of this study is to evaluate discriminative validity of the Young Mania Rating Scale (YMRS) and Childrens Depression Rating Scale–Revised (CDRS-R) in a clinical sample of children when administered in an unfiltered manner (i.e., regardless of whether symptoms occur in a mood episode). The Kiddie Schedule for Affective Disorders and Schizophrenia is the gold standard for assessing psychiatric disorders in children and was used to make diagnoses in this study. Using a sample of 707 treatment-seeking youth (ages 6–12 years, Mage = 9.7 years, 67.6% male), receiver operating curve analyses were performed and diagnostic likelihood ratios (DLRs) were calculated to evaluate the ability to change the odds and differentiate bipolar disorder from other disorders (using the YMRS) and depression from other disorders (using the CDRS-R). Using unfiltered administration, the YMRS achieved good discriminative validity when classifying bipolar disorder compared to other disorders (Area Under the Curve [AUC] = .86) and increased odds of a bipolar diagnosis given a score in the highest quintile (DLR = 6.12). Using unfiltered administration, the CDRS-R achieved moderate to good discriminative validity in classifying depressive disorders (DD) compared to other disorders (AUCBD in comparison = .78; AUCBD not in comparison = .84) and slightly increased odds of DD given a score in the highest quintile (DLRBD in comparison = 3.12; DLRBD not in comparison = 5.08). The YMRS and CDRS-R have moderate to good discriminative validity when administered in an unfiltered way in a sample of treatment seeking youth.