Prognosis

Comorbid conditions often complicate bipolar disorder, and may account for what appears to be the long duration of episodes and poor intermorbid function.[160] In cases where comorbidity is low or parents with bipolar disorder were lithium responders, prognosis is better.[208][209]

There are two published, naturalistic follow-up studies that specifically address children and young adolescents with bipolar disorder. One study selected children (ages 9-13 years) diagnosed as having current mania defined with elation and grandiosity, specifically defined by the authors.[74] The second, the Course and Outcome of Bipolar Youth (COBY) study, includes both children and adolescents who could have had either lifetime or current mania.[210] In these children, age of onset was dated from first mood episode, which means their depressive episode could have been in childhood and their manic episode in adolescence. Many feel that early age of onset carries a worse prognosis, but that may depend on how age of onset is defined, and data on outcome have not yet been documented in adulthood.

Data from other studies report that duration of episode (or time to remission), when remission is defined as 8 weeks of either no symptoms or subthreshold symptoms, is quite different in children from that seen in adults.

Children from the first study mentioned (with mania defined using modified criteria for elation and grandiosity, and who had a mean age at intake of 11 years) had the duration of the index manic episode measured in years (3.6 [±2.5]) rather than months.[74] The COBY study, where the mean age was 13 years, reported a median episode duration of 78 weeks, although the 78-week duration reported included depressive as well as manic, mixed, and hypomanic episodes.[210] However, as mentioned, episodes may have been defined differently between these 2 studies.

In both of the above studies, recovery from the index episode occurred in 80% to 90% of cases, and relapse rates were between 60% and 70%. Subthreshold symptoms of mania, depression, and/or comorbid symptoms may have remained after the criteria for mania (or depression) were no longer met. Not surprisingly, there is considerable functional impairment, although whether this was from partially remitted mood symptoms or from enduring comorbidities is unclear. The COBY study reported 4 different longitudinal mood trajectories: "predominantly euthymic" (24.0%), "moderately euthymic" (34.6%), "ill with improving course" (19.1%), and "predominantly ill" (22.3%). Within each class, young people were euthymic on average 84.4%, 47.3%, 42.8%, and 11.5% of the follow-up time, respectively. Better course was associated with older age of onset of mood symptoms, less lifetime family history of bipolar disorder and substance abuse, and less history at baseline of severe depression, manic symptoms, suicidality, subsyndromal mood episodes, and sexual abuse.[211] Anxiety disorders were common and also associated with a poorer prognosis.[161]

Other risk factors for longer episode duration include nonadherence with pharmacologic treatment, rapid cycling, psychotic symptoms, low socioeconomic status, ADHD, and/or disruptive behavior disorders and a negative parenting style.[16][212][213]

Adolescent-onset bipolar disorder

Childhood- and adolescent-onset bipolar disorder have also been shown to be associated with significantly more unfavorable illness characteristics, including lifetime comorbid anxiety disorder, at least 10 lifetime mood episodes, lifetime alcohol use disorder, and prior suicide attempt, compared with those with adult-onset disorder.[214]

Childhood-onset bipolar disorder

Children who are being given a diagnosis of bipolar disorder in the community have problems with their explosive, aggressive behavior. If these behaviors cannot be modified by treatment, children are in danger of being placed in more restrictive academic and social environments.[215] Individuals with childhood- but not adolescent-onset bipolar disorder are more likely to have significantly more first-degree relatives with mood disorder, lifetime substance use disorder, and rapid cycling.[214]

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