Depression can be the first symptom of bipolar disorder in children and adolescents - what is worth knowing about the disease?

In bipolar disorder, behaviors typical of depression, such as lowered mood, prolonged sadness and depression, lack of feeling joy in life, indifference, desire for isolation, sense of meaninglessness of life, often suicidal thoughts, alternate with periods of mania and hypomania: agitation, irritability, tendency to impulsive behavior, aggression.

Until recently, ChAD was mainly diagnosed in adults, but it turns out that in recent years it has been increasingly diagnosed in children. Even in 30-60 percent of people, the first symptoms appear as early as the teenage years, although in this age group the disease is extremely difficult to diagnose, especially since depression is often its first symptom. - Even in about 80 percent of cases, bipolar disorder in children and adolescents begins with a depressive episode, and such a diagnosis is often made initially. This is because in this age group there are usually no typical symptoms of mania (which cannot be missed); rather, there are episodes of hypomania: irritability, elevated mood or even aggression, considered to be behaviors typical of adolescence or ADHD or conduct disorder, says Dr. Aleksandra Lewandowska, national consultant in child and adolescent psychiatry.

Epidemiological data, however, indicate that ChAD affects about 1.8 percent of children and adolescents, and 2.6-6.6 percent in the over-14 group alone. Over the past few years, there has been a significant increase in the number of reported cases of bipolar disorder, an increase still particularly evident after the COVID-19 pandemic. In 2022, 2,418 people used health services, compared to 843 in 2014, a threefold increase in the number of pediatric patients with a diagnosis of ChAD using health services. Such a trend is an important signal to the health care system, to pay attention to this health problem as well, and to provide appropriate preventive measures for both adults and children and adolescents affected by the disease.

"The noticeable increase in the incidence of bipolar disorder among children and adolescents sends an alarming message to our health care system. Over the past decade, the number of diagnoses in this area has been growing at the fastest rate of any other mental disorder, and after the COVID-19 pandemic, this trend has increased even more. Therefore, people with this disease cannot go unnoticed in the health care system, and it is necessary to include this group of patients in the planned system solutions." - says Urszula Szybowicz, president of the Foundation You Can't See Past Me

Disturbing change in behavior

The difficulty of making a correct diagnosis also stems from the fact that episodes of depression and mania (hypomania) can change rapidly in a teenager, even several times a day, and mixed episodes are common. - We recently diagnosed a 10-year-old boy with a previous diagnosis of depression, admitted to us after a suicide attempt. During the hour-and-a-half-long examination, the boy initially had a depressed mood, cried, and claimed he saw no way he could ever leave the hospital. After a while he jumped on the bed, laughed, said the world was beautiful, was in a euphoric mood. And in a moment, he sat up again and cried, saying that when he looked at the window, he thought about hurting himself, Dr. Lewandowska added.

The basis for making a diagnosis is careful observation of the child, taking a thorough history from the parents. - Parents should also pay attention to the child's disturbed diurnal rhythm, shortened night sleep, disturbed sleep phase, although sometimes the opposite is true: excessive sleepiness appears. Other worrisome symptoms may relate to nutrition; increased appetite or a complete lack of it. One can see a change in the behavior of the child, who ceases to fulfill the role of daughter/son, colleague, pupil/student, stops taking care of hygiene, risky, defiant behavior appears. However, one behavior cannot be taken into account, one must pay attention to the whole context. A child psychiatrist must have a lot of experience, support himself with a very thorough family history in order to make the right diagnosis," notes Professor Malgorzata Janas-Kozik, head of the Department of Clinical Psychiatry and Psychotherapy of the Developmental Age at the Silesian Medical University in Katowice.

Need for safe pharmacotherapy

Genetic factors predispose to the development of ChAD, but environmental factors also influence its development. - The disease causes neuroanatomical changes that are evident in the structure and functioning of the central nervous system; including areas that are involved in the processing and regulation of emotions, impulse control, logical thinking, and the ability to anticipate the consequences of decisions, Dr. Aleksandra Lewandowska stresses.

The disease has a biological basis, so in addition to psychotherapy and environmental interventions, properly selected pharmacotherapy is essential. - In mild or even sometimes moderate depressive disorders, time-limited psychotherapeutic interventions can be considered as the first course of treatment, and pharmacotherapy can be implemented only if they prove ineffective. In bipolar affective disorder, this is not an option. If the patient has experienced an episode of mania, hypomania with a depressive episode, then it requires pharmacological treatment. Psychotherapy is only an additional form of treatment support," points out Marta Tyszkiewicz-Nwafor, MD, from the Department of Psychiatry at the Poznan University of Medical Sciences.

- In the course of bipolar affective disorder, there is a disruption of the relay, mainly dopaminergic, noradrenergic and glutamatergic; we use preparations to sort them out. The basis is pharmacotherapy, because if we do not achieve remission or a significant reduction in symptoms, it is difficult to implement appropriate psychosocial interactions, as the patient is not able to cooperate with us," confirms Dr. Aleksandra Lewandowska.

Drug treatment has to be used for many years, hence it is necessary to select drugs in such a way that they are as safe as possible and have as few side effects as possible (this includes excessive weight gain, metabolic syndrome, negative effects on the cardiovascular system). The problem is that many of the drugs used in mental disorders, including ChAD, do not have registration in children and adolescents, as there have been no clinical trials performed in this age group. - With knowledge and guided by the welfare of the patient, we are obliged to treat them with due diligence based on available modern methods. If we decide to use a preparation that is not registered in Poland in the pediatric patient population, we use it as an off-label treatment, i.e. outside the indications of registration," Dr. Lewandowska points out.

Recommending appropriate pharmacotherapy will be facilitated by the Polish recommendations for the treatment of bipolar affective disorder in children and adolescents, which are being prepared by a team of experts. The problem, however, in many cases may be the cost of treatment, which must be administered over many years. In Poland, it is possible to use reimbursable drugs in the pediatric and adolescent population for mania and mixed episodes. - However, there is no reimbursable preparation that we can use in depressive episodes in adolescent patients in the course of ChAD. Such a preparation is already FDA-registered from the age of 10, recommended by well-known scientific societies around the world. It has the least risk of side effects, negligible effects on weight gain and the cardiovascular system. However, not all parents can afford to pay 100 percent of the drug's price, Dr. Lewandowska points out.

Well-chosen pharmacotherapy allows the child to function normally in the peer group, finish school, study, enter the profession. - Treatment makes it possible to enjoy life to the fullest, to study, to get the profession the young person dreams of. However, this is years of work, and parents and the young person must cooperate with the treating physician, take joint responsibility for the treatment, " Prof. Janas-Kozik points out.

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World Bipolar Disorder Day is celebrated annually on March 30, the anniversary of the birth of Vincent van Gogh, who was posthumously diagnosed with the disorder. On this day, education and awareness initiatives are undertaken to help eliminate the stigma associated with bipolar disorder and support those living with it.

Bipolar disorder is a behavioral mental disorder characterized by extreme changes in mood, thinking, energy and behavior. Bipolar affective disorder was formerly known as manic depression because a person's mood can oscillate between the "poles" of mania (periods of heightened mood) and depression (periods of lowered mood). During a depressive episode, a person experiences lowered mood (sadness, irritability, emptiness), loss of pleasure or interest in activities for most of the day, almost every day. Manic symptoms may include euphoria or irritability, increased activity or energy, and other symptoms such as increased talkativeness, quick thinking, increased self-esteem, decreased need for sleep, ease of distraction and impulsive behavior. People with bipolar disorder are at increased risk of suicide. Currently, however, there are effective treatment options.

In 2019, 40 million people experienced bipolar disorder, with about 0.5 percent of the population struggling with the disease.

Source: press mat.