Bipolar Disorders: Mixed States, Rapid-Cycling, and Atypical Forms

243 Bipolar disorder in children and adolescentsFig. 10.3Percentage of subjects5045403530252015105044.4Suicide attempts22.2*1.2***Bipolar MDD Nevermentallyill908886848280787674727068Global assessment of function74.983.6***87.5***BP MDD NMIBipolar disorder in high-school students. MDD, major depressive disorder; BP, bipolardisorder; NMI, never mentally ill. Asterisks, significant P-values less than 0.05.varied significantly by polarity of the index episode. Recovery was most rapid insubjects with pure mania (mean, 9 weeks) or mixed states (mean, 11 weeks) atintake, followed by subjects who were cycling at the time of presentation (mean,15 weeks). In contrast, a strikingly protracted time to recovery was observed insubjects with pure depression at intake (mean, 26 weeks). Forty-four percent of thesubjects who recovered from their index episode had one or more relapse bycompletion of the 5-year follow-up. Subjects with cycling or mixed episodes atintake had the highest probability of recurrence (mixed/rapid cyclers: 60% versus40% around week 60 after intake). If minor depression and hypomania wereincluded, the recurrence was approximately 60% for patients whose index episodewas mania or depression, 70% for mixed, and 80% for rapid cyclers.Geller et al.(2002a) followed a group of 93 outpatients aged 10.9 2.7 years old(57% prepubertal, 39% females, 89% Caucasian) every 6 months for 2 years. Mostof the sample ( 70%) had comorbid disorders with ADHD and/or oppositionaldefiant disorder, psychosis (60%) and rapid cycling (77%). At intake the meanduration of the index episode was 3.6 years. After 1 year, approximately 37% of thesample showed recovery (no mania or hypomania and a Child-Global AssessmentScale (C-GAS) 60 for 2 weeks) but the rates of relapse/recurrence were 38%.After 2 years of follow-up, the proportions of subjects who recovered from maniaand who relapsed after recovery were 65.2% and 55.2%, respectively. The meantime to recovery was 36 weeks. Relapse occurred after a mean of 28 weeks. Livingwith an intact family improved the chance of recovery and low level of maternalwarmth increased the risk to relapse. Only 50% of the sample was treated withantimanic medications and there were no demographic or clinical predictors ofrelapse/recurrence.Recently a multicenter pilot study (Birmaher, 2001) evaluated 73 outpatientadolescents with BP-I (mean age 17.1 1.8 years, 75% female, 84% Caucasian)