Rate and predictors of prepubertal bipolarity during follow-up of 6- to 12-year-old depressed children. Four-year prospective outcome and natural history of mania in children with a prepubertal and early adolescent bipolar disorder phenotype. Diagnostic characteristics of child bipolar I disorder: does the "Treatment of Early Age Mania (team)" sample generalize? Early-onset bipolar disorder and treatment delay are risk factors for poor outcome in adulthood. A preliminary evaluation of the validity of at-risk criteria for bipolar disorders in help-seeking adolescents and young adults. Bipolar outcome in the course of depressive illness. Phenomenologic, familial, and pharmacologic predictors. Mood episodes and mood disorders: patterns of incidence and conversion in the first three decades of life. Risk for bipolar illness in patients initially hospitalized for unipolar depression. Does psychomotor agitation in major depressive episodes indicate bipolarity? Long-term symptomatic status of bipolar I vs. bipolar II disorders. Efficacy and tolerability of lithium in treating acute mania in youth with bipolar disorder: protocol for a systematic review Heterogeneity of DSM-IV major depressive disorder as a consequence of subthreshold bipolarity. Evaluating differential developmental trajectories to adolescent-onset mood and psychotic disorders A Consecutive Series of Treated Affected Offspring of Parents with Bipolar Disorder: Is Response Associated with the Clinical Profile? Switching from 'unipolar' to bipolar II. An 11-year prospective study of clinical and temperamental predictors in 559 patients. Family history of suicidal behavior and early traumatic experiences: additive effect on suicidality and course of bipolar illness? A prognostic study of clinical dimensions in adolescent-onset psychoses.
OBJECTIVE To investigate the rate and predictors of onset of DSM-III bipolar I and bipolar II disorders among 6- to 12-year-old prepubertal subjects with DSM-III major depressive disorder ( MDD ) who were followed for a 2- to 5-year period . METHODS This was a prospect i ve , blindly rated study of 79 children with MDD and 31 normal control children matched for age , gender , and socioeconomic status . Subjects and a second informant were assessed at 4-month intervals using the Kiddie Schedule for Affective Disorders and Schizophrenia-Present Episode Version-1986 modified to include 4-month interval ratings and to include DSM-III diagnoses .  Family history ( FH ) was assessed using the FH- Research Diagnostic Criteria obtained from the mother about the subject 's first- and second-degree relatives . RESULTS Bipolarity developed in 31.7 % ( N = 25 ) of the children with MDD at a mean age of 11.2 + /- 2.0 years and 80 % were prepubertal . Loaded FH and multigenerational FH were significantly associated with bipolar I. Neither prior nor current use of tricyclic antidepressants nor atypical depressive features were predictive . CONCLUSIONS These findings strongly support the need to educate families of children with prepubertal-onset MDD about the possibility of the emergence of manic and hypomanic symptoms to encourage early recognition and appropriate treatment BACKGROUND Diagnosis of child mania has been contentious . OBJECTIVE To investigate natural history and prospect i ve validation of the existence and long-episode duration of mania in children . DESIGN Four-year prospect i ve longitudinal study of 86 subjects with intake episode mania who were all assessed at 6 , 12 , 18 , 24 , 36 , and 48 months . The phenotype was defined as DSM-IV bipolar I disorder ( manic or mixed ) with at least 1 cardinal symptom ( elation and /or gr and iosity ) to ensure differentiation from attention-deficit/hyperactivity disorder . Parent and child informants were separately interviewed , by highly experienced research nurses , using the Washington University in St Louis Kiddie Schedule for Affective Disorders and Schizophrenia ( WASH-U-KSADS ) . A Children 's Global Assessment Scale score of 60 or less was needed to establish definite impairment . Treatment was by subjects ' community practitioners . SETTING Research unit in a university medical school . PARTICIPANTS Subjects were obtained from psychiatric and pediatric sites by consecutive new case ascertainment , and their baseline age was 10.8 + /- 2.7 years . Onset of the baseline episode  was 7.4 + /- 3.5 years . ( Data are given as mean + /- SD . ) MAIN OUTCOME MEASURES Episode duration , weeks ill , recovery/relapse rates , and outcome predictors . RESULTS Prospect i ve episode duration of manic diagnoses , using onset of mania as baseline date , was 79.2 + /- 66.7 consecutive weeks . Any bipolar disorder diagnosis occurred during 67.1 % + /- 28.5 % of total weeks , during the 209.4 + /- 3.3 weeks of follow-up . Subjects spent 56.9 % + /- 28.8 % of total weeks with mania or hypomania ( unipolar or mixed ) , and 38.7 % + /- 28.8 % of these were with mania . Major or minor depression and dysthymia ( unipolar or mixed ) occurred during 47.1 % + /- 30.4 % of total weeks . Polarity switches occurred 1.1 + /- 0.7 times per year . Low maternal warmth predicted faster relapse after recovery from mania ( chi(2 ) = 13.6 , P = .0002 ) , and psychosis predicted more weeks ill with mania or hypomania ( F(1,80 ) = 12.2 , P = .0008 ) . Pubertal status and sex were not predictive . ( Data are given as mean + /- SD . ) CONCLUSIONS These findings vali date the existence , long-episode duration , and chronicity of child mania . Differences from the natural history of adult bipolar disorder are discussed OBJECTIVE To examine the representativeness of a r and omized controlled trial ( RCT ) sample versus one obtained by consecutive new case ascertainment , for subjects with child bipolar I disorder . METHOD Subjects ( N = 247 ) were out patients who participated in either the National Institute of Mental Health-funded Phenomenology and Course of Pediatric Bipolar Disorders study or the Treatment of Early Age Mania ( TEAM ) study . Both studies required that subjects have current DSM-IV bipolar I disorder ( manic or mixed phase ) and a Children 's Global Assessment Scale ( CGAS ) score < or=60 . All subjects had elation and /or gr and iosity . Subjects in the Phenomenology study were obtained from 1995 to 1998 by consecutive new case ascertainment from design ated pediatric and psychiatric facilities . Subjects in the  TEAM RCT were recruited from media and community sources between March 2003 and March 2005 . Assessment instruments included the Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia , given separately to parents about their children and to children about themselves , and the CGAS . Logistic regression was used for comparisons . RESULTS The TEAM and Phenomenology groups were similar in age ( 10.4 [ SD = 2.3 ] , 10.9 [ SD = 2.3 ] years , respectively ) and other demography . Both had long current episode duration ( 4.8 [ SD = 2.4 ] , 3.2 [ SD = 2.3 ] years ) and low lifetime use of any mood stabilizer ( 23.6 % , 35.0 % ) . Many mania symptoms and ultradian rapid cycling , psychosis , and suicidality were significantly more prevalent in the RCT sample . CONCLUSIONS Generalization of the RCT sample was supported , because only 7.8 % of Phenomenology subjects did not fit the RCT criteria . Nevertheless , because the RCT subjects were more severely ill , it is unclear if treatment findings from the RCT will be applicable to children with less severe mania . CLINICAL TRIALS REGISTRATION Clinical Trials.gov identifier NCT00057681 ( TEAM study ) OBJECTIVE We examined the influence of age at onset of illness and the delay in time to first treatment on morbidity in adulthood . METHOD 529 adult out patients with a mean age of 42 years , who entered our research network from 1996 through 2001 and who were diagnosed with bipolar disorder according to DSM-IV criteria , were rated prospect ively on a daily basis with the National Institute of Mental Health-Life Chart Method during naturalistic treatment for up to 4 years . RESULTS Fifty percent of patients had illness onset in childhood ( < 13 years of age ) or adolescence ( 13 - 18 years of age ) . In year 1 of follow-up , these patients , compared to those with adult onset , showed significantly ( P<.05 ) greater severity of depression and mania , greater number of episodes , more days depressed , more days of ultradian cycling , and fewer days euthymic . After 4 years , the mean severity and duration of depression remained greater and the number of days euthymic fewer in those with childhood compared to adult onset ( P<.05 ) . The delays to first treatment correlated inversely with age at onset of illness . Independently , delay to first treatment was associated with more time depressed , greater severity of depression , greater number of episodes , more days of ultradian cycling , and fewer days euthymic ( all P<.05 ) . CONCLUSIONS These data converge with other evidence that onset of bipolar disorder in childhood is common and often associated with extraordinarily long delays to first pharmacologic treatment . Both childhood onset and treatment delay were associated with a persistently more adverse course of illness rated prospect ively in adults . These data should help foster efforts to ensure earlier and more effective treatment of bipolar illness in children and adolescents . It is hoped that appropriate early intervention would result in a more benign illness and a better prognosis in adulthood INTRODUCTION We have developed ultra-high risk criteria for bipolar affective disorder ( bipolar at-risk - BAR ) which include general criteria such as being in the peak age range of the onset of the disorder and a combination of specific criteria including sub-threshold mania , depressive symptoms , cyclothymic features and genetic risk . In the current study , the predictive validity of these criteria were tested in help-seeking adolescents and young adults . METHOD This medical file-audit study was conducted at ORYGEN Youth Health ( OYH ) , a public mental health program for young people aged between 15 and 24years and living in metropolitan Melbourne , Australia .  BAR criteria were applied to the intake assessment s of all non-psychotic patients who were being treated in OYH on 31 January , 2008 . All entries were then checked for conversion criteria . Hypomania/mania related additions or alterations to existing treatments or initiation of new treatment by the treating psychiatrist served as conversion criteria to mania . RESULTS The BAR criteria were applied to 173 intake assessment s. Of these , 22 patients ( 12.7 % ) met BAR criteria . The follow-up period of the sample was 265.5days on average ( SD 214.7 ) . There were significantly more cases in the BAR group ( 22.7 % , n=5 ) than in the non-BAR group ( 0.7 % , n=1 ) who met conversion criteria ( p<.001 ) . CONCLUSIONS These findings support the notion that people who develop a first episode of mania can be identified during the prodromal phase . The proposed criteria need further evaluation in prospect i ve clinical trials Twenty percent of a cohort of 206 outpatient depressives with no past bipolar history switched during prospect i ve observation . These 41 prob and s developed manic periods on the average of 6.4 years ( median 4 , range 1 - 25 ) after their first depressive episode . The change in polarity occurred throughout the life span , but was most common in adolescence and early adulthood . The following variables were found useful in predicting this outcome : onset less than or equal to 25 years , bipolar family history , loaded pedigrees , precipitation by childbirth , hypersomnic-retarded phenomenology , and pharmacologically-mobilized hypomania . Although the respective sensitivities of these findings were relatively low ( 32 - 71 % ) , their specificities ranged from 69 % to 100 % for bipolar outcome ; the diagnostic specificity of any 3 of these variables when combined was 98 % . When compared with nonbipolar depression , bipolar disorder was seldom chronologically secondary to nonaffective psychiatric disorders . These findings suggest that many young depressives with lethargy and oversleeping are not manifesting a " neurotic " disorder , but rather a precursor of primary bipolar affective disorder . Finally , a psychotically depressed adolescent or young adult with positive bipolar family history should be observed for eventual bipolar outcome , especially when the clinical presentation is that of stupor OBJECTIVES Significant questions remain regarding both the incidence patterns of mood episodes in adolescents and young adults from the community and the conversion rate from unipolar to bipolar disorders . We addressed these issues by examining data from a prospect i ve longitudinal community study to ( i ) determine the cumulative incidence of mood episodes and disorders in the first three decades of life ; ( ii ) determine the risk for first onset of depression among individuals with a previous history of hypomanic/manic episodes and vice versa ; and ( iii ) determine the clinical and treatment characteristics of these subjects . METHODS Using the Munich-Composite International Diagnostic Interview , clinical ly trained interviewers assessed mood episodes and mental disorders in 3,021 community subjects ( aged 14 - 24 at baseline and 21 - 34 at third follow-up ) . RESULTS The estimated cumulative incidence at age 33 was 2.9 % for manic , 4.0 % for hypomanic , 29.4 % for major depressive , and 19.0 % for minor depressive episodes ; overall , 26.0 % had unipolar major depression , 4.0 % bipolar depression , 1.5 % unipolar mania , and 3.6 % unipolar hypomania ( no major depression ) . Overall , 0.6 % and 1.8 % had unipolar mania or hypomania , respectively , without indication for even minor depression . A total of 3.6 % of the initial unipolar major depression cases subsequently developed (hypo)mania , with particularly high rates in adolescent onset depression ( < 17 years : 9 % ) . A total of 49.6 % of the initial unipolar mania cases subsequently developed major depression and 75.6 % major or minor depression . While bipolar cases had more adverse clinical and course depression characteristics and higher treatment rates than unipolar depressed cases , bipolar cases did not significantly differ in mania characteristics from unipolar mania cases . CONCLUSIONS Unipolar and bipolar mood disorders are more frequent than previously thought in adolescence and young adulthood , a time period when both the recognition and the intervention rates by the healthcare system are rather low . ' Conversion ' to bipolar disorder is limited in initial unipolar depression , but common in initial unipolar mania . The remaining unipolar mania cases appear to be significant in terms of clinical and course characteristics and thus require more research attention to replicate these findings OBJECTIVE To assess the risk for subsequent development of mania or hypomania , the authors conducted a 15-year prospect i ve follow-up study of a large , young cohort of patients originally hospitalized for unipolar major depression . METHOD Patients who were hospitalized for unipolar major depression ( N=74 ; mean age=23.0 years , SD=3.8 ) were assessed prospect ively as in patients and then followed up five times over 15 years , at approximately 2 , 5 , 8 , 11 , and 15 years after discharge . Manic or hypomanic episodes , medications , and rehospitalizations were determined by st and ardized assessment s at each follow-up . Polarity conversions were evaluated by survival analyses . RESULTS By the 15-year follow-up , 27 % of the study group had developed one or more distinct periods of hypomania , while another 19 % had at least one episode of full bipolar I mania . Depressed patients with psychosis at the index depressive episode were significantly more likely than nonpsychotic patients to demonstrate subsequent mania or hypomania at follow-up . Those with family histories of bipolar illness showed a nonsignificantly higher rate of switching to mania or hypomania . Spontaneous and antidepressant-associated manias did not differ in frequency . Fewer than one-half of the patients who showed an eventual bipolar course had received prescriptions for mood stabilizers in any follow-up year . CONCLUSIONS Young depressed in patients with psychotic features may be at especially high risk for eventually developing mania . The probability for developing a bipolar spectrum disorder increases in linear fashion for patients at risk for polarity conversion during the first 10 - 15 years after an index depressive episode Abstract Background Kraepelin ’s partial interpretation of agitated depression  as a mixed state of “ manic-depressive insanity ” ( including the current concept of bipolar disorder ) has recently been the focus of much research . This paper tested whether , how , and to what extent both psychomotor symptoms , agitation and retardation in depression are related to bipolarity and anxiety . Method The prospect i ve Zurich Study assessed psychiatric and somatic syndromes in a community sample of young adults ( N = 591 ) ( aged 20 at first interview ) by six interviews over 20 years ( 1979–1999 ) .  Psychomotor symptoms of agitation and retardation were assessed by professional interviewers from age 22 to 40 ( five interviews ) on the basis of the observed and reported behaviour within the interview section on depression . Psychiatric diagnoses were strictly operationalised and , in the case of bipolar-II disorder , were broader than proposed by DSM-IV-TR and ICD-10 . As indicators of bipolarity , the association with bipolar disorder , a family history of mania/hypomania/cyclothymia , together with hypomanic and cyclothymic temperament as assessed by the general  behavior inventory  ( GBI ) [ 15 ] , and mood lability ( an element of cyclothymic temperament ) were used . Results Agitated and retarded depressive states were equally associated with the indicators of bipolarity and with anxiety . Longitudinally , agitation and retardation were significantly associated with each other ( OR = 1.8 , 95 % CI = 1.0–3.2 ) , and this combined group of major depressives showed stronger associations with bipolarity , with both hypomanic/cyclothymic and depressive temperamental traits , and with anxiety . Among agitated , non-retarded depressives , unipolar mood disorder was even twice as common as bipolar mood disorder . Conclusion Combined agitated and retarded major depressive states are more often bipolar than unipolar , but , in general , agitated depression ( with or without retardation ) is not more frequently bipolar than retarded depression ( with or without agitation ) , and pure agitated depression is even much less frequently bipolar than unipolar . The findings do not support the hypothesis that agitated depressive syndromes are mixed states . Limitations The results are limited to a population up to the age of 40 ; bipolar-I disorders could not be analysed ( small N ) Weekly affective symptom severity and polarity were compared in 135 bipolar I ( BP I ) and 71 bipolar II ( BP II ) patients during up to 20 yr of prospect i ve symptomatic follow-up . The course of BP I and BP II was chronic ; patients were symptomatic approximately half of all follow-up weeks ( BP I 46.6 % and BP II 55.8 % of weeks ) . Most bipolar disorder research has concentrated on episodes of MDD and mania and yet minor and subsyndromal symptoms are three times more common during the long-term course . Weeks with depressive symptoms predominated over manichypomanic symptoms in both disorders ( 31 ) in BP I and BP II at 371 in a largely depressive course ( depressive symptoms=59.1 % of weeks vs. hypomanic=1.9 % of weeks ) . BP I patients had more weeks of cyclingmixed polarity , hypomanic and subsyndromal hypomanic symptoms . Weekly symptom severity and polarity fluctuated frequently within the same bipolar patient , in which the longitudinal symptomatic expression of BP I and BP II is dimensional in nature involving all levels of affective symptom severity of mania and depression . Although BP I is more severe , BP II with its intensely chronic depressive features is not simply the lesser of the bipolar disorders ; it is also a serious illness , more so than previously thought ( for instance , as described in DSM-IV and ICP-10 ) . It is likely that this conventional view is the reason why BP II patients were prescribed pharmacological treatments significantly less often when acutely symptomatic and during intervals between episodes . Taken together with previous research by us on the long-term structure of unipolar depression , we su bmi t that the thrust of our work during the past decade supports classic notions of a broader affective disorder spectrum , bringing bipolarity and recurrent unipolarity closer together . However the genetic variation underlying such a putative spectrum remains to be clarified Background Epidemiological , clinical , and high-risk studies have provided evidence that the peak period for onset of diagnosable episodes of mania and hypomania starts in mid-to-late adolescence . Moreover , clinical ly significant manic symptoms may occur even earlier , especially in children at familial risk . Lithium is the gold st and ard treatment for acute mania in adults , yet to our knowledge , there is no published systematic review assessing lithium treatment of mania in children or adolescents . This is a major gap in knowledge needed to inform clinical practice . Aim As a working group within the ISBD Task Force on Lithium Treatment ( http://www.isbd.org/active-task-forces ) , our aim is to complete a systematic review of the efficacy , tolerability , and acceptability of lithium compared with placebo and other active drugs in treating mania in children and adolescents diagnosed with bipolar disorder . Methods We will include double- or single-blind r and omized controlled trials in patients aged less than 18 years . No restrictions will be made by study publication date or language . Several electronic data bases will be search ed along with secondary sources such as bibliographies and trial registry websites for published and unpublished studies . Response rates to lithium compared with placebo or other active drugs will be the primary efficacy outcome . Primary tolerability and acceptability outcomes will be rates of serious adverse events and dropouts , respectively . Secondary outcomes will include rates of remission , severity of manic symptoms at different time points , and incidence of specific adverse events . Discussion Findings from this systematic review are critically needed to inform clinical practice . We should not generalize findings from adult studies , as children and adolescents are undergoing accelerated physiological and brain development . Therefore , efficacy , tolerability , and acceptability of lithium treatment of acute mania in children compared to adults may be very different . This systematic review has been registered in PROSPERO ( CRD42017055675 ) CONTEXT There is growing evidence that major depressive disorder ( MDD ) might be overdiagnosed at the expense of bipolar disorder ( BPD ) . OBJECTIVES To identify a subgroup of subthreshold BPD among DSM-IV MDD , which is distinct from pure MDD regarding a range of validators of bipolarity , and to examine the pattern of these validators among different groups with affective disorders . DESIGN Ten-year prospect i ve longitudinal and family study including 3 follow-up waves . Data were assessed with the DSM-IV Munich Composite International Diagnostic Interview . SETTING Community sample in Munich , Germany . PARTICIPANTS A total of 2210 subjects ( aged 14 - 24 years at baseline ) who completed the third follow-up . MAIN OUTCOME MEASURES Cumulative incidence of pure MDD , BPD , and subthreshold BPD ( defined as fulfilling criteria for MDD plus having manic symptoms but never having met criteria for [hypo]mania ) . RESULTS Among 488 respondents with MDD , 286 ( 58.6 % ) had pure MDD and 202 ( 41.4 % ) had subthreshold BPD  ( cumulative incidence , 9.3 % ) . Compared with respondents who had pure MDD , respondents with subthreshold BPD were found to have a significantly increased family history of mania , considerably higher rates of nicotine dependence and alcohol use disorders , rates of panic disorder that were twice as high , and a tendency toward higher rates of criminal acts . Prospect i ve analyses showed that subthreshold BPD converted more often into BPD during follow-up , with DSM-IV criterion D ( symptoms observable by others ) being of critical predictive relevance . With increasing severity of the manic component , rates for diverse validators accordingly increased ( eg , alcohol use disorders , parental mania ) or decreased ( harm avoidance ) . CONCLUSIONS Data suggest that MDD is a heterogeneous concept including a large group with subthreshold BPD , which is clinical ly significant and shares similarities with BPD . Findings might support the need for a broader concept and a more comprehensive screening of bipolarity , which could be substantial for future research and adequate treatment of patients with bipolarity Background It is an open question as to whether differential developmental trajectories , potentially representing underlying pathophysiological processes , can form the basis of a more useful typology in young persons who present for mental health care . Methods A cohort of 605 young people was recruited from youth mental health services that target the early phases of anxiety , mood or psychotic disorders . Participants were assigned to one of three clinical sub-types ( anxious-depression ; mania-fatigue ; developmental-psychotic ) according to putative developmental trajectories . Results The distribution of subtypes was : 51 % anxiety-depression , 25 % mania-fatigue and 24 % developmental-psychotic , with key differences in demographic , clinical , family history and neuropsychological characteristics . When analyses were limited to 286 cases with ‘ attenuated ’ or sub-threshold syndromes , the pattern of differences was similar . Multinomial logistic regression demonstrated that compared to the developmental-psychotic subtype , both the mania-fatigue and anxiety-depression subtypes were younger and more depressed at presentation , but less functionally impaired . Other discriminating variables between the developmental-psychotic and mania-fatigue sub-types were that the latter were significantly more likely to have a family history of bipolar disorder but have less likelihood of impaired verbal learning ; whilst the anxious-depression group were more anxious , more likely to have a family history of depression , and had a higher premorbid IQ level . Conclusions This cross-sectional evaluation provides preliminary support for differing developmental trajectories in young persons presenting for mental health care . Prospect i ve follow-up is needed to examine the predictive validity of this approach and its relationships to underlying pathophysiological mechanisms Objective : In adults with established bipolar disorder ( BD ) , differential response to  mood stabilizers  has been associated with the clinical profile . Long-term treatment studies of youth with BD are lacking . This paper provides longitudinal observations of response to  mood stabilizers  early in the course of illness in youth with BD . Method : We report on 15 research patients who , as adolescents , met DSM-IV lifetime criteria for a bipolar spectrum disorder and required long-term treatment . These youths derived from families with one parent having BD whose course and long-term treatment response were determined in accordance with research criteria . The patients were offered lithium , and if they failed to respond or refused it , they were treated with either an anticonvulsant or an atypical antipsychotic . Using a vali date d scale , an independent rater retrospectively blindly scored the response to long-term treatment . Results : Those patients who stabilized on  lithium  derived from lithium-responsive families , whereas those who stabilized on an  antipsychotic  derived from lithium-nonresponsive families . The clinical course in the youths stabilized by lithium differed from that in the youths stabilized by an atypical antipsychotic . Conclusions : Our findings suggest that the clinical profile may help in selecting effective stabilizing treatment and that a proportion of youth can be stabilized on monotherapy . This is a small case series with nonr and om treatment assignment , and the findings should be considered tentative BACKGROUND Given the therapeutic and prognostic importance of the unipolar-bipolar dichotomy , predicting which patients will become bipolar subsequent to index diagnosis of major depressive disorder ( MDD ) is of paramount clinical significance . We sought to characterize the profile of patients with MDD who would convert to the more subtle bipolar subtype ( known as BPII ) on the basis of clinical and personality variables obtained during MDD episodes . METHODS A total of 559 patients , comprehensively evaluated with the Schedule of Affective Disorders and Schizophrenia and " unipolar " MDD at entry , were administered 17 self-report personality measures .  Hypomanic and manic episodes were systematic ally recorded over a prospect i ve observation period of up to 11 years . We compared 48 converters to BPII ( 8.6 % ) with 22 converters to bipolar I ( BPI ) ( 3.9 % ) and the remaining larger group of unipolar patients . RESULTS Except for greater acuteness , severity , and psychotic symptomatology , BPI converters were essentially similar to MDD nonconverters . By contrast , BPII converters were robustly distinguished from those with MDD who remained unipolar on the basis of self-report measures along the newly derived factors of Mood Lability , Energy-Activity , and Daydreaming . This profile was associated with early age at onset of MDD and pleomorphic psychopathology beyond the usual affective realm , high rates of substance abuse , as well as educational , marital , and occupational disruption and minor antisocial acts prior to discrete hypomanic episodes . Overall , BPII switchers had a more protracted and tempestuous course with shorter well intervals . " Habitual self " descriptions of temperamental instability during MDD episodes provided useful clinical information for predicting which depressed patients will switch to BPII , attaining a sensitivity of 91 % for all three factors combined ( 23 items ) ; Mood Lability alone ( nine items ) was the most specific predictor ( 86 % ) , though of lower sensitivity ( 42 % ) . CONCLUSIONS The BPII subtype is best understood by such lability intruding into , and possibly its accentuation during , depressive episodes , thereby creating an intimate interweaving of trait and state . Clinicians must note that the foregoing temperamental profile appears more fundamental in defining the affective dysregulation of the BPII subtype than hypomanic episodes emphasized in DSM-IV BACKGROUND Bipolar disorder ( BD ) is associated with a high prevalence of suicide attempt and completion . Family history of suicidal behavior and personal history of childhood abuse are reported risk factors for suicide among BD subjects . METHODS BD individuals with family history of suicidal behavior and personal history of childhood abuse ( BD-BOTH ) , BD individuals with family history of suicidal behavior or personal history of childhood abuse ( BD-ONE ) , and BD individuals with neither of these two risk factors ( BD-NONE ) were compared with regard to demographic variables and clinical measures . RESULTS Almost 70 % of the sample had a history of a previous suicide attempt . There were significantly higher rates of previous suicide attempts in the BD-BOTH and BD-ONE relative to the BD-NONE group . BD-BOTH were significantly younger at the time of their first suicide attempt and had higher number of suicide attempts compared with BD-NONE . BD-BOTH were significantly younger at the time of their first episode of mood disorder and first psychiatric hospitalization and had significantly higher rates of substance use and borderline personality disorders compared to BD-NONE . LIMITATIONS Retrospective study . Use of semi-structured interview for the assessment of risk factors . CONCLUSIONS BD individuals with a familial liability for suicidal behavior and exposed to physical and /or sexual abuse during childhood are at a greater risk to have a more impaired course of bipolar illness and greater suicidality compared to those subjects with either only one or none of these risk factors . Prospect i ve studies are needed to confirm these findings Adolescent-onset psychoses often raise diagnostic difficulties because of the mixture of schizophrenic and affective features . This study examined prospect ively which clinical dimensions contribute to difficulty in initial diagnosis and which clinical features have predictive value for outcomes of  schizophrenia  or affective disorders  , and for eventual psychosocial functioning .  Thirty-six adolescents consecutively admitted for a psychotic episode were followed up for 1 to 4 years . Symptoms were assessed at admission , at discharge , and once a year . DSM-III-R ( APA 1989 ) diagnoses were assessed at admission and once a year . Comparisons were performed across initial and followup diagnostic groups . Positive symptoms did not differentiate the initial clinical pictures , while negative symptoms , manic symptoms , and disorganization differentiated the manic and depressive episodes in the acute phase . When initial positive symptoms ( mainly delusions ) were severe , they predicted a final diagnosis in the schizophrenia spectrum . Poor outcome was associated with more anhedonia-associality and lower functioning scores at admission . Results suggest ( 1 ) a higher vulnerability to positive symptoms in adolescents who will further develop schizophrenia and ( 2 ) the low specificity of affective symptoms at this age
Comparison of manic symptoms across age groups suggested that irritability is a key feature of BD with an onset in childhood , activity is the most prominent in adolescent-onset BD and pressure of speech is more characteristic of adult-onset BD .
Conclusions Despite frequent discussion of similarities and differences in phenomenology of mania presenting in different age groups , systematic research is lacking and studies are still required to reliably establish whether the frequency and severity of manic symptoms varies .
Background In the last two decades , there has been a significant increase in the diagnosis of Bipolar Disorder ( BD ) in children .
The notion of prepubertal onsets of BD is not without controversy , with research ers debating whether paediatric cases have a distinct symptom profile or follow a different illness trajectory from other forms of BD .
The latter issue is difficult to address without long-term prospect i ve follow-up studies .
However , in the interim , it is useful to consider the phenomenology observed in groups of cases with different ages of onset and particularly to compare manic symptoms in children diagnosed with BD compared to cases presenting with BD in adolescence and adulthood .
This review systematic ally explores the phenomenology of manic or hypomanic episodes in groups defined by age at onset of BD ( children , adolescents and adults ; or combined age groups e.g. children and adolescents versus adults ) .