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

244 B. Birmaher and D. Axelsonwith the K-SADS Present and Epidemiological version and followed them every4 months with the Longitudinal Interval Follow-up Evaluation (LIFE) for 4–224weeks (mean 76 62 weeks). Approximately 68% of the subjects recovered (LIFEpsychiatric status rating ¼ 1–2 for 8 weeks) in 20–40 weeks. It took significantlylonger for the mixed (mean ¼ 58 weeks) BP patients to recover than those withmanic (mean ¼ 42 weeks) or depressive (mean ¼ 20 weeks) presentations. Despitethe high recovery rate, 59% of the patients had at least one recurrence, with mixedBP patients having more recurrences and shorter periods before the onset of therecurrent episode (mania ¼ 79 weeks, depression 30 weeks and mixed 26 weeks, 2 ¼ 6–8, df ¼ 2, P ¼ 0.03). During the follow-up time, almost all patients were onpsychotropic medication and 26% of the follow-up time patients received threemedications (e.g., mood stabilizer, antidepressants, and stimulants). Moreover,70% had hospitalizations and the patient’s BP illness caused a severe family,interpersonal, and economic burden.In summary, the few longitudinal studies have helped to validate the diagnosisof BP disorder in youth and have shown that this illness, in particular the mixedand rapid-cycling subtypes, is protracted and causes significant psychosocial andacademic impairment.Family historyVery few bottom-up (first-degree relatives of children and adolescents) and top-down(offspring of BP children) studies have been published (DelBello and Geller, 2001).Bottom-up studiesStrober et al. (1998) found that, compared with adolescents with schizophrenia,youth with BP disorder have a high prevalence of first- (and second-) degreerelatives with BP disorder. Likewise, Faraone et al. (1997) found that children withongoing mood lability and severe temper outbursts diagnosed with ‘‘continuous’’BP disorder had significantly more first-degree relatives with BP disorder thanchildren with only ADHD. These results suggest that these children (or at leastsome) may indeed be suffering from BP disorder. The problem with this study,however, is that children were not directly interviewed and the assessment wasonly done with the K-SADS-Epidemiologic version (Orvashel et al., 1982) thatdoes not adequately evaluate BP disorder in children.Top-down studiesTaking into account all the difficulties in diagnosing BP disorder in childrendescribed above, it appears that, in comparison with offspring of parents withnon-BP disorders, and normal children, offspring of BP parents are five to seven