Ross J. Baldessarini

Pediatric-Onset Bipolar Disorder: A Neglected Clinical and Public Health Problem Gianni

&NA; Bipolar disorder (BPD), probably the most prevalent psychotic disorder in adults, has been relatively neglected or controversial in children and adolescents over the past century. We reviewed the literature on early‐onset BPD.* Estimates of prevalence, particularly before puberty, are limited by historical biases against pediatric mood disorders and by formidable diagnostic complexity and comorbidity. Although clinical features of pediatric and adult BPD have similarities, pediatric cases probably cannot be defined solely by features characteristic of adult cases. Onset was before age 20 years in at least 25% of reported BPD cases, with some increase in this incidence over the past century. Pediatric BPD is familial more often than is adult‐onset BPD, may be associated with a premorbid cyclothymic or hyperthymic temperament, and can be precipitated by antidepressant treatment. Pediatric BPD episodes frequently include irritability, dysphoria, or psychotic symptoms; they are commonly chronic and carry high risks of substance abuse and suicide. BPD is often recognized in adolescents, but the syndrome or its antecedents are almost certainly underrecognized and undertreated in children. Controlled studies of short‐and long‐term treatment, course, and outcome in this disorder remain strikingly limited, and the syndrome urgently requires increased clinical and scientific interest.

Bipolar (Manic-Depressive) Disorder

Bipolar (manic-depressive) disorder is a severe syndrome involving episodic shifts of mood into mania or depression, with variations in severity, frequency, clinical presentation, and complexity of episodes. Associated risks are high rates of psychosis, anxiety syndromes, and substance abuse. Mortality is increased due to suicide, accidents, and medical complications of substance abuse, as well as stress-sensitive medical disorders. Lifetime prevalence for relatively severe cases is probably more than 2% of the general population, affecting men and women similarly; half of cases begin before age 20. There is a strong familial predisposition but no identified genetics or etiology. Mania sometimes arises in association with neuromedical disorders or reactions to drugs. The long-term course is quite predictable in individuals from early morbidity patterns, but unpredictable across patients. Treatment of mania involves antipsychotics, anticonvulsants, or sedative medicines for mania. Treatment of bipolar depression remains unsatisfactory and the place of antidepressants in such treatments remains controversial. Long-term maintenance treatment with lithium salts or certain anticonvulsants seeks to avoid recurrences, with only partial control, especially of depression. Psychosocial and rehabilitative interventions also are useful components of comprehensive care.