A Consecutive Series of Treated Affected Offspring of Parents with Bipolar Disorder: Is Response Associated with the Clinical Profile? Multifamily psychoeducation groups (MFPG) for families of children with bipolar disorder. Patterns of pharmacological maintenance treatment in a community mental health services bipolar disorder cohort study (SIN-DEPRES). A Pilot Study of Antidepressant-Induced Mania in Pediatric Bipolar Disorder: Characteristics, Risk Factors, and the Serotonin Transporter Gene Family-focused treatment for adolescents with bipolar disorder. Reduced mania and depression in juvenile bipolar disorder associated with long-chain ω-3 polyunsaturated fatty acid supplementation Association between bipolar spectrum features and treatment outcomes in outpatients with major depressive disorder. Integrated family and individual therapy for bipolar disorder: results of a treatment development study. Adjunctive psychosocial intervention following Hospital discharge for Patients with bipolar disorder and comorbid substance use: A pilot randomized controlled trial Course sequences in bipolar disorder: depressions preceding or following manias or hypomanias. Antidepressant-associated switches from depression to mania in severe bipolar disorder. Early psychosocial intervention for youth at risk for bipolar I or II disorder: a one-year treatment development trial. A randomized, controlled, pilot study of dialectical behavior therapy skills in a psychoeducational group for individuals with bipolar disorder. Aripiprazole in juvenile bipolar disorder comorbid with attention-deficit/hyperactivity disorder: an open clinical trial. Efficacy and tolerability of lithium in treating acute mania in youth with bipolar disorder: protocol for a systematic review Augmenting psychoeducation with a mobile intervention for bipolar disorder: a randomized controlled trial. Dialectical behavior therapy for adolescents with bipolar disorder: results from a pilot randomized trial.
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 OBJECTIVES Multi-family psychoeducation groups ( MFPG ) have been developed and tested for adults , but not for children with bipolar disorder ( BPD ) . We present data from a pilot study of our manual-driven MFPG treatment for families of children with mood disorders and address two questions : Do families of children with BPD and families of children with major depressive disorder/dysthymic disorder ( MDD/DD ) : 1 ) differ at treatment entry ? ; 2 ) benefit equally from intervention ? METHOD A total of 35 children ( n=16 , BPD ; n=19 , MDD/DD ) aged 8 - 11 years and their parents were r and omized into immediate MFPG plus treatment as usual ( TAU ) or wait-list + TAU and assessed periodically . RESULTS At baseline , there was a trend toward parents in BPD families being more knowledgeable about mood symptoms than parents in MDD/DD families ( p < 0.04 ) . Additionally at baseline , children with BPD evidence d greater mood severity historically and a trend toward more hospitalizations , day treatment , outpatient treatment , medication trials , and placement in special education classrooms than children with MDD/DD . Immediately following and 4 months post-treatment , both BPD and MDD/DD families described having gained knowledge , skills , support , and positive attitudes during treatment . MDD/DD families increased their knowledge of symptoms to the same level as BPD families . CONCLUSIONS While BPD families enter treatment with more impaired children and more extensive treatment histories , both BPD and MDD/DD families benefit from intervention . The clinical issues concerning combining families of children with bipolar and depressive spectrum illnesses in groups are discussed . Clinical impressions suggest that such combinations are clinical ly feasible and potentially beneficial Maintenance therapy in bipolar disorder ( BD ) is usually required to prevent relapses and improve residual symptoms . Therefore , in this study , we describe patterns of pharmacological maintenance treatment and identify associated clinical features . This prospect i ve multicentre epidemiological study recruited a cohort of 739 consecutive out- patients with clinical ly stable BD . Clinical stability was assessed at baseline with the Clinical Global Impression scale for BD and depressive symptoms with the Hamilton Depression Rating Scale .  Psychotropic medications were classified and analysed according to their mechanism as well as use . Logistic regression models were used to examine the associations between pharmacological strategies and clinical features . Longer time since last episode [ odds ratio ( OR ) 1.002 , p < 0.0001 ] and family history of psychiatric disorders ( OR 1.911 , p = 0.028 ) were associated with lithium in monotherapy ;  manic polarity of the most recent episode ( OR 3.300 , p = 0.006 ) and longer duration of clinical stability ( OR 1.009 , p = 0.034 ) with antipsychotic in monotherapy ;  depressive polarity of the most recent episode ( OR 2.567 , p = 0.003 ) and bipolar II disorder diagnosis ( OR 2.278 , p = 0.008 ) with antidepressant combination ;  no ongoing psychiatric co-morbidity ( OR 0.230 , p = 0.004 ) with lithium and anticonvulsant ;  manic polarity of the most recent episode ( OR 3.774 , p < 0.0001 ) with lithium and antipsychotic ;  manic polarity of the most recent episode ( OR 2.907 , p = 0.028 ) with lithium , anticonvulsant and antipsychotic . The pharmacological patterns followed published recommendations , except for the excessive use of antidepressants . This study reveals clinical factors closely related to prescription patterns BACKGROUND Antidepressant-induced mania ( AIM ) has been described in bipolar disorder ( BD ) and has been associated with the short-allele of the serotonin transporter gene ( 5-HTT ) . We wished to investigate the frequency of and risk factors for AIM in pediatric patients with or at high risk for BD . METHODS Fifty-two children and adolescents ( 30 with BD and 22 with subthreshold manic symptoms , 15.1 + /- 3.4 years old ) , all with a parent with BD , were interviewed with their parents for manic/depressive symptoms occurring before and after past antidepressant treatment .  The 47 subjects with serotonin reuptake inhibitor ( SSRI ) exposure  were genotyped for the 5-HTT polymorphism . RESULTS Fifty percent of subjects were AIM + and 25.5 % had new onset of suicidal ideation . The AIM + and AIM - groups did not differ significantly in relation to allele ( p = .36 ) or genotype ( p = .53 ) frequencies of the 5-HTT polymorphism . The AIM + subjects were more likely to have more comorbidities ( 3.2 vs. 2.4 ; p = .02 ) and be BD type I ( p = .04 ) than AIM - subjects . CONCLUSIONS Youth with or at high risk for BD may be particularly vulnerable to SSRI AIM and thus should be monitored if given SSRIs . In this preliminary study , we did not find that the 5-HTT polymorphism significantly influenced vulnerability to AIM BACKGROUND Research has begun to eluci date the optimal pharmacological treatments for pediatric-onset bipolar patients , but few studies have examined the role of psychosocial interventions as adjuncts to pharmacotherapy in maintenance treatment . This article describes an adjunctive family-focused psychoeducational treatment for bipolar adolescents ( FFT-A ) . The adult version of FFT has been shown to be effective in forestalling relapses in two r and omized clinical trials involving bipolar adults . METHODS FFT-A is administered to adolescents who have had an exacerbation of manic , depressed , or mixed symptoms within the last 3 months . It is given in 21 outpatient sessions of psychoeducation , communication enhancement training , and problem solving skills training . We describe modifications to the adult FFT model to address the developmental issues and unique clinical presentations of pediatric-onset patients . RESULTS An open treatment trial involving 20 bipolar adolescents ( 11 boys , 9 girls ; mean age 14.8+/-1.6 ) found that the combination of FFT-A and mood stabilizing medications was associated with improvements in depression symptoms , mania symptoms , and behavior problems over 1 year . LIMITATIONS These early results are based on a small-scale open trial . CONCLUSIONS Results from an ongoing r and omized controlled trial will clarify whether combining FFT-A with pharmacotherapy improves the 2-year course of adolescent bipolar disorder . If the results are positive , then a structured manual-based psychosocial approach will be available for clinicians who treat adolescent bipolar patients in the community Long-chain ω-3 polyunsaturated fatty acid ( LCn-3PUFA ) supplementation may improve symptoms of depression in children and bipolar disorder ( BD ) in adults . No studies have examined the effectiveness of LCn-3PUFA supplementation in the treatment of mania and depression in juvenile BD ( JBD ) when given as an adjunct to st and ard pharmacological treatment . Eighteen children and adolescents with JBD received supplements containing 360 mg per day eicosapentaenoic acid ( EPA ) and 1560 mg per day docosahexaenoic acid ( DHA ) for 6 weeks in an open-label study . Intake and fasting red blood cell ( RBC ) LCn-3PUFA , mania , depression and global function were assessed before and after supplementation . RBC EPA and DHA were significantly higher following supplementation . Clinician ratings of mania and depression were significantly lower and global functioning significantly higher after supplementation . Parent ratings of internalizing and externalizing behaviours were also significantly lower following supplementation . A larger r and omized controlled trial appears warranted in this participant population CONTEXT It has been suggested that patients with major depressive disorder ( MDD ) who display pretreatment features suggestive of bipolar disorder or bipolar spectrum features might have poorer treatment outcomes . OBJECTIVE To assess the association between bipolar spectrum features and antidepressant treatment outcome in MDD . DESIGN Open treatment followed by sequential r and omized controlled trials . SETTING Primary and specialty psychiatric outpatient centers in the United States . PARTICIPANTS Male and female out patients aged 18 to 75 years with a DSM-IV diagnosis of nonpsychotic MDD who participated in the Sequenced Treatment Alternatives to Relieve Depression ( STAR*D ) study . INTERVENTIONS Open treatment with citalopram followed by up to 3 sequential next-step treatments . MAIN OUTCOME MEASURES Number of treatment levels required to reach protocol -defined remission , as well as failure to return for the postbaseline visit , loss to follow-up , and psychiatric adverse events . For this secondary analysis , putative bipolar spectrum features , including items on the mania and psychosis subscales of the Psychiatric Diagnosis Screening Question naire , were examined for association with treatment outcomes . RESULTS Of the 4041 subjects who entered the study , 1198 ( 30.0 % ) endorsed at least 1 item on the psychosis scale and 1524 ( 38.1 % ) described at least 1 recent maniclike/hypomaniclike symptom . Irritability and psychoticlike symptoms at entry were significantly associated with poorer outcomes across up to 4 treatment levels , as were shorter episodes and some neurovegetative symptoms of depression . However , other indicators of bipolar diathesis including recent maniclike symptoms and family history of bipolar disorder as well as summary measures of bipolar spectrum features were not associated with treatment resistance . CONCLUSION Self-reported psychoticlike symptoms were common in a community sample of out patients with MDD and strongly associated with poorer outcomes . Overall , the data do not support the hypothesis that unrecognized bipolar spectrum illness contributes substantially to antidepressant treatment resistance BACKGROUND Several studies have established the efficacy of psychosocial interventions as adjuncts to pharmacotherapy in the symptom maintenance of bipolar disorder . This study concerned a new psychosocial approach - integrated family and individual therapy ( IFIT ) - that synthesizes family psychoeducational sessions with individual sessions of interpersonal and social rhythm therapy . METHOD Shortly after an acute illness episode , 30 bipolar patients ( DSM-IV criteria ) were assigned to open treatment with IFIT ( up to 50 weekly sessions of family and individual therapy ) and mood-stabilizing medications in the context of a treatment development study . Their outcomes over 1 year were compared with the outcomes of 70 patients from a previous trial who received st and ard community care , consisting of 2 family educational sessions , mood-stabilizing medications , and crisis management ( CM ) . Patients in both sample s were evaluated as to symptomatic functioning at entry into the project and then every 3 months for 1 year . RESULTS Patients in IFIT had longer survival intervals ( time without relapsing ) than patients in CM . They also showed greater reductions in depressive symptoms over 1 year of treatment relative to their baseline levels . The results could not be explained by group differences in baseline symptoms or pharmacologic treatment regimens . CONCLUSION Combining family and individual therapy with medication may protect episodic bipolar patients from early relapse and ongoing depressive symptoms . Further examination of this integrative model within r and omized controlled trials is warranted Bipolar disorder and substance use disorders are highly debilitating conditions , and especially when co-occurring , are associated with a variety of negative outcomes . Surprisingly , there is a relative lack of research on feasible and effective psychosocial treatments for individuals with comorbid bipolar and substance use disorder ( BD-SUD ) , and a dearth of literature examining interventions design ed specifically to improve outcomes such as symptoms , functioning , and treatment engagement/adherence following psychiatric hospitalization in this population . In the current paper , we report results of a pilot r and omized controlled trial ( n=30 ) , comparing the recently developed Integrated Treatment Adherence Program , which includes individual and telephone sessions provided to patients and their significant others , versus Enhanced Assessment and Monitoring for those with BD-SUD . Participants who received the Integrated Treatment Adherence Program demonstrated significantly faster and greater improvements in depression , mania , functioning , and values-consistent living than participants r and omized to Enhanced Assessment and Monitoring , and there was a trend for increased treatment adherence over time . Results are discussed in light of existing literature and study limitations , and suggestions for future research are proposed BACKGROUND Inferior response to lithium treatment  has been reported in bipolar disorder ( BD ) patients with mania or hypomania following episodes of major depression ( DMI ) versus preceding depression ( MDI ) , with intervening euthymic periods . However , additional characteristics of BD course-patterns require further assessment . METHODS We review ed computerized clinical records and life-charts of 855 DSM-IV-TR BD-I or -II patients assessed and followed at mood-disorder centers in Cagliari or Rome to characterize their predominant course-sequences . RESULTS Morbidity over an average of 9.5 cycles in 18 years was characterized for sequencing of illness-episodes and euthymic intervals . Prevalent sequences included : major depression-hypomania ( 15.0 % ) , mania-major depression ( 14.6 % ) , major depression-mania ( 11.6 % ) , and rapid-cycling ( 9.6 % ) . Among subjects grouped by course-sequences ( based on mania , mixed-states , or hypomania and major or minor depression ) , depression-before-[hypo]mania ( DMI ) cases were more likely to be women , diagnosed BD-II , have first-episodes of depressive or anxiety disorder , spend more time ill in depression , and benefit less with long-term mood-stabilizing treatments than with the opposite pattern ( MDI ) . MDI patients were more likely to have substance-abuse and receive long-term mood-stabilizer treatments . Meta- analysis of 5 previous reports plus present findings found inferior treatment-response in DMI vs. MDI cases at a pooled risk-difference of 29 % [ CI : 18 - 40 % ] ( p<0.0001 ) . LIMITATIONS Some data were retrospective and subject to recall bias , and treatment was clinical ( non-r and omized ) . CONCLUSIONS The DMI course was strongly associated with first-episode depression or anxiety , excess depressive morbidity , and inferior treatment response , especially for depression OBJECTIVES To determine whether switching from depression to mania is part of the natural history of bipolar illness or results from antidepressant ( AD ) treatment by examining bipolar patients with psychosis early in their illness course . METHODS A multi-facility cohort of 123 first-admission in patients , aged 15 - 60 years , with DSM-IV bipolar disorder ( BD ) with psychotic features , was followed for four years , and 76 individuals experienced at least one episode of depression .  Frequency of and risk factors for switches from depression to mania , time to switch , and duration of the subsequent manic episode were examined in relation to AD use ( with anti-manic and /or antipsychotic medications ) . RESULTS The 76 respondents experienced 113 depressive episodes . Those prescribed ADs had more depressive episodes and spent more time depressed than non-users . A total of 23 depressive episodes in 17 respondents ended in a manic/hypomanic/mixed episode ( 20 % ) . The time to switch and duration of the subsequent manic episode were not significantly different for the seven respondents and nine episodes involving AD treatment versus the 10 respondents and 14 episodes without ADs . None of the risk factors ( age of onset < or=18 years , childhood psychopathology , depressive first episode , substance abuse at index admission , bipolar family history , type of AD used ) was associated with switching . CONCLUSIONS In this sample with severe BD , switching from depression to mania was not associated with AD treatment . Respondents who experienced switching appeared to have a more relentless form of BD . In only a few did ADs appear to be responsible for the switch OBJECTIVES Previous studies have identified behavioral phenotypes that predispose genetically vulnerable youth to a later onset of bipolar I or II disorder , but few studies have examined whether early psychosocial intervention can reduce risk of syndromal conversion . In a one-year open trial , we tested a version of family-focused treatment adapted for youth at high risk for bipolar disorder ( FFT-HR ) . METHODS A referred sample of 13 children ( mean 13.4±2.69 years ; 4 boys , 9 girls ) who had a parent with bipolar I or II disorder participated at one of two outpatient specialty clinics . Youth met DSM-IV criteria for major depressive disorder ( n=8 ) , cyclothymic disorder ( n=1 ) , or bipolar disorder not otherwise specified ( n=4 ) , with active mood symptoms in the past month . Participants were offered FFT-HR ( 12 sessions in four months ) with their parents , plus psychotropic medications as needed . Independent evaluators assessed depressive symptoms , hypomanic symptoms , and global functioning at baseline and then every four months for one year , with retrospective severity and impairment ratings made for each week of the follow-up interval . RESULTS Families were mostly adherent to the treatment protocol ( 85 % retention ) , and therapists administered the FFT-HR manual with high levels of fidelity . Youth showed significant improvements in depression , hypomania , and psychosocial functioning scores on the Adolescent Longitudinal Interval Follow-up Evaluation . They also showed significant improvements in Young Mania Rating Scale and Children 's Depression Rating Scale scores . CONCLUSIONS FFT-HR is a promising intervention for youth at high risk for BD . Larger-scale r and omized trials that follow youth into young adulthood will be necessary to determine whether early psychosocial intervention can reduce the probability of developing bipolar I or II disorder among genetically vulnerable youth BACKGROUND Bipolar disorder ( BD ) is a chronic and disabling psychiatric disorder characterized by recurrent episodes of mania/hypomania and depression . Dialectical behavior therapy ( DBT ) techniques have been shown to effectively treat borderline personality disorder , a condition also marked by prominent affective disturbances . The utility of DBT techniques in treating BD has been largely unexplored . The purpose of this research was to conduct a pilot study of a DBT-based psychoeducational group ( BDG ) in treating euthymic , depressed , or hypomanic Bipolar I or II patients . METHODS In this experiment , 26 adults with bipolar I or II were r and omized to intervention or  wait-list control groups and completed the Beck depression inventory II , mindfulness-based self-efficacy scale , and affective control scale at baseline and 12 weeks . The BDG intervention consisted of 12 weekly 90-min sessions which taught DBT skills , mindfulness techniques , and general BD psychoeducation . RESULTS Using RM-ANOVA , subjects in BDG demonstrated a trend toward reduced depressive symptoms , and significant improvement in several MSES subscales indicating greater mindful awareness , and less fear toward and more control of emotional states ( ACS ) . These findings were supported with a larger sample of patients who completed the BDG . Furthermore , group attendees had reduced emergency room visits and mental health related admissions in the six months following BDG . LIMITATIONS The small sample size in RCT affects power to detect between group differences . How well improvements after the12-week BDG were maintained is unknown . CONCLUSIONS There is preliminary evidence that DBT skills reduce depressive symptoms , improve affective control , and improve mindfulness self-efficacy in BD . Its application warrants further evaluation in larger studies INTRODUCTION Juvenile bipolar disorder ( JBD ) is a highly impairing chronic mental health condition that affects children and adolescents ' overall functioning . Comorbidity with attention-deficit/hyperactivity disorder ( ADHD ) is extremely prevalent and may determine worse response to treatment . Few investigations have addressed the use of recent atypical antipsychotics in JBD , although several guidelines suggest their use . METHODS We conducted a 6-week open trial with aripiprazole in 10 children and adolescents with JBD comorbid with ADHD to assess impact on mania and ADHD symptoms , respectively , by means of the Young Mania Rating Scale and the Swanson , Nolan and Pelham Scale , as well as on global functioning ( Clinical Global Impressions-Severity ) , and adverse events . RESULTS Significant improvement in global functioning scores ( F=3.17 , P=.01 , effect size=0.55 ) , manic symptoms ( F=5.63 , P<.01 ; ES=0.93 ) , and ADHD symptoms ( t=3.42 , P<.01;ES=1.05 ) were detected . Although an overall positive tolerability was reported , significant weight gain ( F=3.07 , P=.05 ) was observed . CONCLUSION Aripiprazole was effective in improving mania and ADHD symptoms , but neither JBD nor ADHD symptom remission was observed in most of the cases . R and omized placebo-controlled trials for JBD and ADHD are needed 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 ) BACKGROUND Psychosocial interventions for bipolar disorder are frequently unavailable and re source intensive . Mobile technology may improve access to evidence -based interventions and may increase their efficacy . We evaluated the feasibility , acceptability and efficacy of an augmentative mobile ecological momentary intervention targeting self-management of mood symptoms . METHODS This was a r and omized single-blind controlled trial with 82 consumers diagnosed with bipolar disorder who completed a four-session psychoeducational intervention and were assigned to 10 weeks of either : 1 ) mobile device delivered interactive intervention linking patient-reported mood states with personalized self-management strategies , or 2 ) paper- and -pencil mood monitoring . Participants were assessed at baseline , 6 weeks ( mid-point ) , 12 weeks ( post-treatment ) , and 24 weeks ( follow up ) with clinician-rated depression and mania scales and self-reported functioning . RESULTS Retention at 12 weeks was 93 % and both conditions were associated with high satisfaction . Compared to the paper- and -pencil condition , participants in the augmented mobile intervention condition showed significantly greater reductions in depressive symptoms at 6 and 12 weeks ( Cohen׳s d for both were d=0.48 ) . However , these effects were not maintained at 24-weeks follow up . Conditions did not differ significantly in the impact on manic symptoms or functional impairment . LIMITATIONS This was not a definitive trial and was not powered to detect moderators and mediators . CONCLUSIONS Automated mobile-phone intervention is feasible , acceptable , and may enhance the impact of brief psychoeducation on depressive symptoms in bipolar disorder . However , sustainment of gains from symptom self-management  mobile interventions , once stopped , may be limited OBJECTIVE The purpose of this study was to conduct a pilot r and omized trial of dialectical behavior therapy ( DBT ) versus psychosocial treatment as usual ( TAU ) for adolescents diagnosed with bipolar disorder ( BP ) . METHODS We recruited participants 12 - 18 years of age with a primary BP diagnosis ( I , II , or operationalized not otherwise specified [ NOS ] criteria ) from a pediatric specialty clinic . Eligible patients were assigned using a 2:1 r and omization structure to either DBT ( n=14 ) or psychosocial TAU ( n=6 ) . All patients received medication management from a study -affiliated psychiatrist . DBT included 36 sessions ( 18 individual , 18 family skills training ) over 1 year . TAU was an eclectic psychotherapy approach consisting of psychoeducational , supportive , and cognitive behavioral techniques . An independent evaluator , blind to treatment condition , assessed outcomes including affective symptoms , suicidal ideation and behavior , nonsuicidal self-injurious behavior , and emotional dysregulation , quarterly over 1 year . RESULTS Adolescents receiving DBT attended significantly more therapy sessions over 1 year than did adolescents receiving TAU , possibly reflecting greater engagement and retention ; both treatments were rated as highly acceptable by adolescents and parents . As compared with adolescents receiving TAU , adolescents receiving DBT demonstrated significantly less severe depressive symptoms over follow-up , and were nearly three times more likely to demonstrate improvement in suicidal ideation . Models indicate a large effect size , for more weeks being euthymic , over follow-up among adolescents receiving DBT . Although there were no between-group differences in manic symptoms or emotional dysregulation with treatment , adolescents receiving DBT , but not those receiving TAU , evidence d improvement from pre- to posttreatment in both manic symptoms and emotional dysregulation . CONCLUSIONS DBT may offer promise as an adjunct to pharmacotherapy in the treatment of depressive symptoms and suicidal ideation for adolescents with BP . The DBT focus on commitment to treatment may be important for the treatment of early-onset BP . Larger controlled trials are needed to establish the efficacy of this approach , examine impact on suicidal behavior , and demonstrate cost effectiveness
RESULTS There is sufficient evidence for a Grade A recommendation of the use of olanzapine plus fluoxetine at reducing depressive symptoms in bipolar depression and of quetiapine at high doses for depressive symptoms occurring during mixed episodes .
These results mostly overlap with the approved treatments for bipolar depression in adults
BACKGROUND The management of depressive and mixed symptoms in children and adolescents with bipolar disorder ( BD ) remains a matter of debate .
The goal of this review is , thus , to systematic ally examine the impact of atypical antipsychotics ( AAPs ) and mood stabilisers in the treatment of bipolar depression and /or mixed states .