martes, octubre 21, 2008

Trastorno Bipolar I desde la infancia

En Archives of General Psychiatry 2008; 65(10):1125-1133; ha aparecido un artículo interesante sobre el trastorno bipolar I en niños.

Los autores descubrieron que el 44 por ciento de los sujetos con TBP-I estudiados desde niños continuaron con los episodios de manía en la edad adulta, y que un 35 por ciento tenía desórdenes de uso de substancias. De esta manera se respalda la hipótesis de la continuidad desde la infancia hasta la adultez del TBP-I.

Geller et al found that 44.4% of grown-up subjects with child bipolar I disorder continued to have manic episodes, and 35.2% had substance use disorders, strongly supporting the continuity of child and adult bipolar I disorders. In addition, characteristics of postbaseline episodes, including long episode duration, daily cycling, and psychosis, were largely similar to those of the first (baseline) episode. Even accounting for familial psychopathology, low maternal warmth significantly predicted earlier relapse after recovery.

October 15, 2008 — New research suggests bipolar disorder is a continuous disease that can begin in childhood.

The pioneering study — the first to prospectively demonstrate the disorder can begin in childhood and extend into adulthood — shows that up to 44% of children who experience manic episodes as children continue to experience them as young adults.

"This paper provides support [to the idea] that mania in children exists, because if you follow very young children with the disorder into adulthood, the illness continues," principal investigator Barbara Geller, MD, from Washington University, in St. Louis, Missouri, told Medscape Psychiatry.

The study is published in the October issue of the Archives of General Psychiatry.

Difficult Diagnosis to Swallow

The first National Institute of Mental Health–funded group to describe child bipolar I disorder, Dr. Geller's research team was also the first to demonstrate that the condition has higher familial aggregation than that found in similar studies of adult bipolar I disorder.

Nevertheless, she said, the concept of bipolar disorder in childhood is a difficult one for many parents and clinicians to accept. Further, recent data showing enormous increases in the chart-review diagnoses of pediatric bipolar has fueled further skepticism about its existence.

"The thought that a child can be too happy, too cocky, too exuberant, is anathema to many people. But when we're talking about childhood bipolar I disorder, we are talking about children who are so silly and giddy that families are asked not to bring them to church; who are so cocky, expansive, and grandiose that they go to the principal's office and tell them to fire teachers they don't like; bright kids who fail classes because they are fully convinced they know it all and don't study," she said.

The importance of the current paper was to determine whether mania in childhood is different from adult mania or a continuation of the same disorder.

The prospective, longitudinal study included 115 children with an average age of 11 years diagnosed with a first episode of child bipolar disorder during the period from 1995 to 1998 and followed for 8 years.

During 9 follow-up visits, the children and their parents were interviewed separately about symptoms, diagnoses, daily cycles of mania and depression, and interactions with others.

More Effective Medications Needed

The study had a very high retention rate, with 108 of 115 (93.9%) children assessed at all 9 follow-up points. Participants' average age at follow-up was 18.1 years. At the end of follow-up, the results of the study revealed that all of the children had a mood disorder over 60.2% of the time and that episodes of mania occurred 39.6% of the time.

The authors report that although 87.8% of subjects recovered from mania, 73.3% relapsed. Low maternal warmth predicted earlier relapse. When investigators examined the characteristics of children's second and third episodes of mania, they found they were similar to the first episode and characterized by psychosis, daily cycling between mania and depression, and a long duration — 55.2 weeks for the second episode and 40 weeks for the third.

When investigators separately analyzed data from the 54 participants who had reached the age of 18 years at the end of the follow-up period, they found that 44.4% continued to have manic episodes. In addition, 35.2% had substance-use disorders, a rate similar to those diagnosed with bipolar I disorder as adults.

According to Dr. Geller, the 44% frequency rate of manic episodes among those 18 years and older with bipolar disorder is 13 to 44 times higher than the population prevalence. In addition, she pointed out the rate is also much higher than repeat episodes in comparable studies of bipolar I disorder in adult populations.

These findings, said Dr. Geller, strongly support the hypothesis that bipolar disorder in childhood continues into adulthood and "shows the illness is continuous, providing validation, as does our previous family study, that mania actually exists in children and that it is continuous with the adult disorder."

Currently, she added, treating bipolar disorder — in both children and adults — is challenging.

"Generally, the current medications don't work as well as we would like them to work, so that at this point the approach for any individual patient is based very much on trial and error," she said.

"Also, because low maternal warmth predicted a worse outcome, treatment plans need to include evaluation of mother-child relationships," Dr. Geller added.

Growing Awareness

Finally, said, Dr. Geller, it is important that physicians are aware that mania in children does exist and that they know, at least at this time, that outcomes are poor, so that they can appropriately counsel families.

Future research includes following these study subjects well into adulthood to further examine outcomes. The group also plans to publish neuroimaging and further genetic findings from the same cohort in the near future.

In an accompanying editorial, Ellen Leibenluft, MD, from the National Institute of Mental Health, in Bethesda, Maryland, said the study contributes to a growing awareness that serious mental illnesses do not emerge de novo when individuals reach adulthood but rather reflect early developmental processes.

She points out that this study extends previous seminal work on pediatric bipolar disorder and highlights the need for more research that will eventually foster "work that will allow us to treat youth with bipolar disorder more effectively and eventually give us the knowledge base needed to prevent the onset of bipolar disorder."

The study was supported by the National Institute of Mental Health. The authors report no relevant conflicts of interest.

FUENTE: MedScape Medical News y Archives of General Psychiatry

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