The challenges of treating bipolar disorder in young people
Paediatric bipolar disorder severely affects normal development and psychosocial functioning, and increases the risk for behavioural, academic, social and legal problems, as well as psychosis, substance abuse and suicide.
I was doing research and interviews on bipolar disorder when notices appeared in my Brooklyn neighborhood about a 21-year-old man who had been missing for a week. He was described as “bipolar” and “may be experiencing a manic episode.”
It took me back nearly seven decades when the state police in Texas called my father to say they had found his brother, my favorite uncle, wandering on a highway. How he got there from Brooklyn we never learned. He had apparently suffered a psychotic break and ended up in a New York State mental hospital that administered electric shock treatments but did little else to help him re-enter society effectively.
Not until decades later did he receive a correct diagnosis of manic depression, now known as bipolar disorder. Characterized by extreme shifts in mood, “manic-depressive illness” was officially recognised by the American Psychiatric Association in 1952. But it would be many years before an effective treatment, the drug lithium, which acts on the brain to help stabilise debilitating episodes of severe mania and depression, was available to help my brilliant uncle resume a reasonably normal life.
Bipolar disorder typically runs in families, with different members experiencing symptoms to a greater or lesser degree. If a parent has the disorder, a child’s risk can rise to 10 per cent. My uncle’s only child displayed some minor behavioural characteristics of bipolar disorder, like very rapid speech and frenetic activity, but was able to complete two advanced degrees, marry, be a parent and succeed in an intellectually demanding career.
Bipolar disorder typically runs in families, with different members experiencing symptoms to a greater or lesser degree.
Bipolar disorder is most often diagnosed in the later teen years or young adulthood, affecting some 4 per cent of people at some point in their lives. But in recent decades, diagnosis of the disorder has soared in children and adolescents, although some experts believe the condition is over-diagnosed or over-treated with potent psychiatric drugs.
Symptoms in children may initially be mistaken for other conditions, such as ADHD (attention deficit/hyperactivity disorder) or oppositional defiant disorder, and young people may suffer serious distress at home and in school for years. As David Miklowitz, professor of psychiatry at UCLA School of Medicine, told me, there is still “an average lag of 10 years between the onset of symptoms and getting proper treatment.”
Based on studies of patients’ histories, Dr Boris Birmaher, professor of psychiatry at the University of Pittsburgh School of Medicine, reported, “In up to 60 per cent of adults with bipolar disorder, onset of mood symptoms occurred before age 20. However, pediatric bipolar disorder is often not recognised, and many youth with the disorder do not receive treatment or are treated for comorbid conditions rather than bipolar disorder.”
The longer it takes to start appropriate treatment, the worse the adult outcomes.
Yet, Dr Birmaher, who specialises in early-onset bipolar disease, argues: “Paediatric bipolar disorder severely affects normal development and psychosocial functioning, and increases the risk for behavioural, academic, social and legal problems, as well as psychosis, substance abuse and suicide. The longer it takes to start appropriate treatment, the worse the adult outcomes.”
With early detection, which is most likely to occur when there is a family history of bipolar disorder, some affected young people may respond well to family and behavioural therapy that obviates the need for medication, Dr Miklowitz suggested.
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There is often resistance to treating children with drugs. Dr Terence A Ketter, retired professor of psychiatry at Stanford University, said one problem is that “faced with a bunch of badly behaved children, authorities want to give them antipsychotics to make them behave, but if they’re over-treated they can become like zombies.” In agreement with Dr Miklowitz, he said, “On average it takes about a decade and three different doctors to get children the right diagnosis and treatment.”
Another challenge to proper diagnosis and treatment stems from the boundless energy and extraordinary productivity and creativity that can accompany bouts of mania. Not until the mania reverts to severe depression or, as happened to my uncle, psychosis, might a young person with bipolar disorder be likely to receive needed medical attention.
Ronald Braunstein, conductor of the Me2 Orchestra he created with Caroline Whiddon to support talented people with mental illness, recalled that he was riding a manic wave of artistic achievement in his early 20s when a crippling depression caused a professional and personal crash. Yet for decades he was not treated properly and experienced repeated cycles of great successes as a conductor followed by major failures.
I asked Braunstein, now 65 and for the last 14 years finally being treated effectively for bipolar disorder, what he recalled about early signs of his mental illness.
“Everything seemed off in my early teens – I didn’t feel emotionally balanced,” he said. “Things were weirder than they should have been as a teenager. My father once took me to a psychiatrist who diagnosed me as having ‘bad nerves.’”
As he described one early symptom of mania, “I wanted to learn how to fly, and I thought if I ran down a hill fast enough and tilted my hands in a certain angle I would have flown. In high school I told fellow students I knew how to fly and I went to the top of a building to demonstrate. Fortunately, they talked me down.”
He said, “I didn’t know what was wrong or that it could be treated.” He added that for parents of teenagers, who may have difficulty recognising abnormal behaviour in adolescents, “it’s sometimes hard to distinguish what is illness and what is normal grandiosity or normal sadness that might have been caused by a breakup with a girlfriend.”
Dr Birmaher noted that young people with bipolar disorder usually have recurring episodes of major depression, but that “depressive episodes are not necessary for making the diagnosis.” For some, mania is the primary symptom.
When depression is the symptom that brings patients to professional attention, the correct diagnosis can be especially tricky. As Dr Ketter explained, depressed individuals may be unable to recall previous episodes of mania that occurred when they were not depressed.
Dr Miklowitz said one of the first signs of bipolar disorder is “mood dysregulation – the child is angry or depressed one moment, then is excited and happy and full of ideas moments later.”
He listed characteristics of mania that can help parents distinguish them from normal teenage highs and lows. The symptoms, several of which should be noticeable to other people, can include “grandiose thinking, decreased need for sleep, rapid or pressured speech and/or flight of ideas, racing thoughts, distractibility, excessive goal-driven activity, and impulsive or reckless behavior,” Dr Miklowitz said.
With depressive symptoms, he suggests looking for “an impairment in functioning – suddenly not going to school or going late, not finishing homework, sleeping through classes, a drop in grades, not wanting to eat with anyone else, talking about suicide, self-cutting.”
Depending on the severity of a child’s impairment, if non-life-threatening symptoms are caught in the early teens, Dr Miklowitz said it may be possible to start with psychotherapy and avoid medication, which has side effects. “But if the child’s life is at risk, if he can’t function at home or at school, medication may be the answer,” he said. “There are risks to not medicating.”
When medication is necessary, he said, the dosage should be just high enough to control symptoms and not be overly sedating.
By Jane Brody © The New York Times
This article originally appeared in The New York Times.