Suicide and Youth with Bipolar Disorder

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Suicide and Youth with Bipolar Disorder

By Tami D. Benton, M.D., Elizabeth B. Weller, M.D., Ronald A. Weller, M.D.

Bipolar disorder, also known as manic-depressive illness, is a mood disorder in which episodes of depression alternate with periods of mania. Sometimes an individual may feel both extremes of mood at virtually the same time. The cause of manic-depressive illness is not known.

However, heredity plays a significant role. Adult onset bipolar disorder has long been identified as a familial disorder, and now child and adolescent onset disorder has been shown to run in families. Frequently, the condition begins in adolescence and, occasionally, during childhood. While well studied in adults, the characteristics, clinical course, treatment and prognosis are not as well understood for children and adolescents.

Fortunately, information about manic-depressive illness in youth has increased in recent years. For example, recent research shows that adolescents with bipolar disorder demonstrate a high frequency of mixed manic states, suicidality, and more depressive features than adults with the disorder. Also, children who have their first episode of manic-depressive illness prior to puberty, more often have a chronic and continuous course rather than an acute and episodic course that is often seen in adults.Children frequently demonstrate a rapid-cycling, mixed affective state that may be comorbid with attention-deficit/hyperactivity disorder (ADHD) and/or conduct disorder.
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These new findings highlight the importance of early identification and treatment of children and adolescents with bipolar disorder. Children with bipolar disorder can also manifest manic symptoms that are considered atypical. The changes in mood, level of psychomotor agitation, and mental excitement are often markedly labile and erratic rather than persistent. Irritability, belligerence, and mixed manic-depressive features are more common than euphoria. Twenty to thirty percent of youth with a major depressive disorder go on to have manic episodes.

Risk factors for mania in youth are depressive episodes with rapid onset, psychomotor retardation and psychosis; a family history of mood disorders (especially bipolar illness); and a history of mania/hypomania with antidepressant treatment.
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Although the estimated lifetime prevalence in the general population is 0.80 percent, childhood onset bipolar disorder has been considered rare. More recent case reports, however, challenge this assumption. Approximately twenty percent of all patients with bipolar illness have their first episode during adolescence.Peak age of onset is between fifteen and nineteen years. Varying presentations of the illness in children and adolescents may lead to under-diagnosis. The presentation may be complicated by psychotic symptoms, mixed manic-depressive symptoms, and severe deterioration of behavior.

Youth are more likely to have a diagnosis of bipolar II disorder or cyclothymic disorder rather than bipolar I disorder. Mild episodes of depression or hypomania are mistakenly attributed to adjustment disorders or adolescent turmoil.Ethnic minorities and individuals from lower socioeconomic backgrounds are at greater risk for a misdiagnosis of schizophrenia.

Early manifestation of affective disorders may also be attributed to other disorders such as ADHD, school phobia or conduct disorder According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV),one or more manic episodes, mixed episodes, or hypomanic episodes characterize the bipolar disorders. One or more episodes of depression may have also occurred. While bipolar disorder may begin with either manic or depressive symptoms, in children depression is more often the initial presentation.
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Symptoms of a major depressive episode include:

Persistent sadness; frequent tearfulness. Loss of pleasure in previously favored activities. Frequent somatic complaints (e.g. stomachaches, headaches). Lowered energy, poor concentration, complaints of boredom. Major changes in eating and sleeping behaviors (e.g. overeating or disrupted sleep patterns).

Symptoms of a manic episode include:

Severe changes in mood when compared to peers (e.g. unusually happy or silly, or highly irritable). Unrealistic highs in self-esteem. Notable increases in energy; need for sleep greatly decreased. Excessive speech; talks too much, too fast and changes topics quickly. Distractibility; attention moves quickly from one thing to the next. Risky behavior (e.g. jumps from roof believing no harm will occur).

A diagnosis of bipolar disorder should be considered for any youth with a marked deterioration in function associated with either mood or psychotic symptoms. Bipolar disorders also have a high rate of comorbidity with ADHD, conduct disorder, and substance abuse.
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It is also increasingly clear that adolescents with bipolar disorder are at increased risk of suicide. Both children and adolescents who have bipolar disorder have a high incidence of completed suicide.

Psychological autopsy studies show that ninety percent of adolescent suicides occur in individuals with a pre-existing psychiatric disorder. Approximately fifty percent of these had a psychiatric diagnosis for two years or more. Mood disorders are the most common psychiatric illnesses associated with increased suicidality among adolescents. Alcohol or drug use and aggressive or disruptive behaviors are also major risk factors for suicide in youth.

Goodwin and Jamison (1990) offer evidence that suicide attempts occur early in the course of manic-depressive illness.There is also an increased risk of suicide during a first episode of a mood disorder. Thus, a good psychiatric evaluation of adolescents with bipolar disorder should routinely include assessment of suicide potential.

Suicide occurs in ten to fifteen percent of all persons with a bipolar disorder. Studies by Strober et al. (1995) found that twenty percent of their adolescent patients had made at least one medically significant suicide attempt.

Brent et al. (1993) compared sixty-seven suicide completers with community matched controls and found a high incidence of adolescents with bipolar mixed states.

Substance abuse further increased mortality rates. Because of the mistaken societal belief that children do not attempt suicide, it is not unusual for the suicidal behaviors of children who have attempted suicide to be unrecognized or assumed to be accidental.

Thus, it must always be recognized that this population is at significant risk for attempted/completed suicide. Once this disorder is accurately diagnosed, youth with bipolar disorder can be effectively treated. Evidence suggests that medication, specifically a mood stabilizer, is the best treatment for manic-depressive illness.
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Concurrent psychotherapeutic, psychoeducational and community based interventions (which address ethnic and cultural issues) are also important components of a complete multi-modal treatment plan. Treatment should be initiated after thorough evaluation by a child and adolescent psychiatrist.
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A comprehensive treatment plan should include:

Initiation of medication therapy with mood stabilizers to reduce the number and severity of manic and depressive episodes.

Mood stabilizing medications currently used include lithium, valproate and carbamazepine.

Individual, group or family psychotherapy to help the child or adolescent recognize and adapt to stress, build self-esteem, improve familial and social relationships, and address additional psychosocial factors that increase morbidity.

Psychoeducational therapy for the patient includes ongoing education about the illness and treatment (including medication effects) and developing problem-solving skills and basic life skills.

Psychoeducational intervention for the patient's family focuses on increasing knowledge of the illness, treatment options, prognosis, relapse prevention, and strategies for parenting interventions.

Treatment of comorbid disorders or symptoms such as substance use, disruptive behavior, and suicidal behavior. Lithium has traditionally been the agent of first choice in the treatment of bipolar disorder, and has the largest database to support its efficacy. In adults lithium has been effective in the treatment of acute mania and depression, prevention of recurrence, and stabilization of moods between episodes.

While there are fewer methodologically sound controlled studies on which to base treatment decisions for bipolar children and adolescents, open and placebo controlled studies evaluating the efficacy of lithium treatment in children and adolescents are promising.

Other mood stabilizers such as valproate and carbamazapine are widely used to treat bipolar disorder in children and adolescents although their efficacy has not yet been clearly demonstrated in controlled studies. Efficacy for these medications, primarily valproate, has been demonstrated in adults. For children and adolescents with bipolar disorder who present suicidal thoughts, gestures or attempts, urgent evaluation by a mental health professional is indicated.

Treatment for these behaviors, regardless of the underlying disorder, must focus on decreasing the severity of suicidal behaviors, reducing the risk factors and preventing the onset of further suicidal episodes. Acute management of suicidal behaviors must begin with a detailed discussion with the patient and family about the factors that might promote further suicidal behaviors and methods for coping with unavoidable stressors.

The goal is to begin the process of developing problem-solving skills with the family and patient on how to prevent recurrence. If the patient and family cannot develop these skills, other more restrictive interventions to maintain patient safety such as inpatient psychiatric care may be needed.

The child or adolescent who has attempted suicide or plans to attempt suicide should be hospitalized if:
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His or her mood state or mental state makes his or her behaviors unpredictable, such as the presence of command auditory hallucinations or rapid cycling with irritable or impulsive behaviors. The child or adolescent is unable to regulate emotions or behaviors. He or she is intoxicated with alcohol or drugs. The child or adolescent cannot or will not commit to a safety contract, be truthful with caregivers about suicidal feelings or thoughts, or form a therapeutic alliance with the therapist.The child or adolescent lacks a supportive, responsible adult or adequate environmental support for the maintenance of safety. Patients and families must be warned about the disinhibiting effects of drugs and alcohol and the importance of providing a safe environment by removing or securing firearms and/or lethal medications.

There must be supervision by a responsible adult who will insure that follow-up appointments are kept. It is extremely important to have a supportive person in the environment. If these conditions are met and the child or adolescent can make a commitment to working with the family and mental health care providers towards these goals, he or she may be safely managed in a less restrictive outpatient setting.
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To summarize, the most effective intervention for the prevention of suicide in children and adolescents with bipolar disorder is early recognition, accurate diagnosis, and aggressive treatment. Depressed and suicidal children and adolescents with bipolar disorder should be started on a mood stabilizer prior to antidepressant treatment. Adjunctive psychopharmacological treatment for associated symptoms with benzodiazepines and neuroleptics, however, may exacerbate suicidal ideation and do not appear to reduce the risk of suicidal ideation or behavior.
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Bipolar illness is treatable.

Suicidal talk by children and adolescents should not be ignored. Actions that can be construed as suicidal behavior must be recognized as such and should prompt a thorough evaluation by a mental health professional. While researchers continue to describe the nature of bipolar illness in youth, it is clear that early identification and intervention can prevent the needless loss of young lives.

Ongoing research should provide new information on juvenile onset bipolar illness that will further enhance its recognition and treatment.
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Elizabeth Weller, M.D. is a professor of psychiatry and pediatrics at the University of Pennsylvania and a member of AFSP's Scientific Council.
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NAMI's efforts focus on support to persons with serious brain disorders and to their families; advocacy for nondiscriminatory and equitable federal, state, and private-sector policies; research into the causes, symptoms and treatments for brain disorders; and education to eliminate the pervasive stigma surrounding severe mental illness.

http://www.afsp.org/education/weller.htm

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