BIPOLAR ILLNESS: WHAT IS DIFFERENT ABOUT YOUNG PEOPLE - A report on a presentation¹ by Gabrielle A. Carlson, M.D.,² Smooth Sailing, Spring 1998

Dr. Gabrielle A. Carlson stated that children and adolescents with bipolar disorder warrant special attention, since 20 to 30 percent of bipolar patients experience the onset of their illness before the age of 25. Also, she cautioned that diagnosing adolescents can be particularly challenging because 1) they often have had no prior episodes, and 2) their symptoms of mania or hypomania [relatively mild mania] are clearly associated with other psychopathology, such as ADHD/ODD [attention deficit hyperactivity disorder/oppositional defiant disorder]. Symptoms shared by mania and ADHD/ODD include hyperactivity, impulsivity, distractibility, and emotional lability. Adolescents who have externalizing disorders [conduct/behavioral disorders] or who are substance abusers are particularly vulnerable to bipolar illness, and substance-abusing patients with bipolar illness have four times the usual rate of conduct disorders. In the adolescent population, uncomplicated bipolar illnesses are rare.

Studies suggest that rates of mixed mania [symptoms of mania and depression appearing simultaneously] and comorbid mania [mania coexisting with another disorder] are higher in young people than in the adult population. In about 80 percent of the adolescent/young adult group, the illness first occurs as depression, with mania following as long as three to four years later. A psychotic depression often indicates that a bipolar illness will follow, and there is often a family history of mood disorders.

Not surprisingly, Dr. Carlson observed, outcomes are worse in adolescents than in patients first diagnosed with bipolar illness after age 30. Adolescents with comorbid disorders fare worse than adults in terms of their ability to get along in the work environment, even though they can return to their former level of functioning. Not only do these early-onset patients have more persistent substance abuse, but they also have more recurrence of mood episodes.

There are several important considerations in treating this population of adolescent bipolar patients who have comorbid externalizing disorders and substance abuse. These patients need comprehensive treatment planning and special education. Medication alone is unlikely to eliminate the patient's psychopathology, since the mood disorder and the externalizing disorders and the substance abuse need to be treated. Not surprisingly, medications for mood disorders are also used to treat aggression. The medications, then, are likely to be needed all the time, not just during a mood disorder episode. Since bipolar illness runs in families, it may also be necessary to treat the parents.

In summary, adolescents with bipolar illness deserve special attention because they truly have special needs.

¹Presented at a DRADA/Johns Hopkins symposium, Baltimore, MD, April 30, 1998.
²Professor of Psychiatry and Pediatrics, Director of Child and Adolescent Psychiatry, State University of New York at Stonybrook.

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