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Prospective Continuity With Adult Bipolar I Disorder; Characteristics of Second and Third Episodes; Predictors of 8-Year Outcome

Barbara Geller, MD; Rebecca Tillman, MS; Kristine Bolhofner, BS; Betsy Zimerman, MA

Arch Gen Psychiatry. 2008;65(10):1125-1133.

Context  Child bipolar I disorder (BP-I) is a contentious diagnosis.

Objective  To investigate continuity of child and adult BP-I and characteristics of later episodes.

Design  Inception cohort longitudinal study. Prospective, blinded, controlled, consecutive new case ascertainment.

Setting  University medical school research unit.

Subjects  There were 115 children, enrolled from 1995 through 1998, aged 11.1 (SD, 2.6) years with first episode DSM-IV BP-I, mixed or manic phase, with 1 or both cardinal symptoms (elation or grandiosity) and score of 60 or less on the Children's Global Assessment Scale (CGAS). All DSM-IV severity and duration criteria were fulfilled. Separate interviews were conducted of parents about their children and of children about themselves.

Main Outcome Measures  Washington University in St Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS); Psychosocial Schedule for School Age Children–Revised; CGAS.

Results  Retention was 93.9% (n = 108) for completing assessments at every one of the 9 follow-up visits. Subjects spent 60.2% of weeks with any mood episodes and 39.6% of weeks with mania episodes, during 8-year follow-up. During follow-up, 87.8% recovered from mania, but 73.3% relapsed to mania. Even accounting for family psychopathology, low maternal warmth predicted relapse to mania, and more weeks ill with manic episodes was predicted by low maternal warmth and younger baseline age. Largely similar to first episodes, second and third episodes of mania were characterized by psychosis, daily (ultradian) cycling, and long duration (55.2 and 40.0 weeks, respectively), but significantly shorter than first episodes. At 8-year follow-up, 54 subjects were 18.0 years or older. Among subjects 18.0 years or older, 44.4% had manic episodes and 35.2% had substance use disorders.

Conclusions  In grown-up subjects with child BP-I, the 44.4% frequency of manic episodes was 13 to 44 times higher than population prevalences, strongly supporting continuity. The rate of substance use disorders in grown-up child BP-I was similar to that in adult BP-I.

Author Affiliations: Department of Psychiatry, Washington University in St Louis, St Louis, Missouri.

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