Interventions for Youth at Risk of Bipolar Disorder

Abstract

Opinion statementWith the recognition that bipolar disorder (BD) develops in a series of predictable clinical stages, clinical and research focus has shifted increasingly into early intervention and prevention. The heritability of BD is estimated to be around 85 %; therefore, children of affected parents are an identifiable and important high-risk group. Lessons from early psychosis and other areas of medicine suggest that education for high-risk families regarding recognizable clinical stages and modifiable risk factors are a reasonable starting place. Specifically, reinforcing the importance of healthy nutrition, cardiovascular exercise, maintaining normal body mass index, and healthy coping strategies are important topics to cover. Early risk syndromes include sleep and anxiety disorders, which should be addressed with low-risk treatments, including sleep hygiene and individual psychotherapy. Typically, adolescence marks the age of onset of depressive disorders related to the bipolar diathesis. This is also the time when poor coping through substance abuse emerges. It is very important when assessing a depressed adolescent to understand the familial risk of psychiatric disorders. While psychotherapy is typically effective for mild non-psychotic depression, the acute treatment of moderate-severe major depression in adolescents and young adults with a confirmed family history of BD is a topic of considerable debate. The treatment decision should be taken together with the patient and family, with full discussion of the risks and potential benefits. Options include a closely monitored trial of low-dose antidepressant, discontinued immediately upon resolution of the depressive episode, or mood stabilizer that fits the patient profile, or a combination of these two, in addition to psychotherapy and reducing modifiable risk factors. When a high-risk subject manifests a diagnosable manic or hypomanic episode (typically years after the first depressive episode in late adolescence or adulthood) the question arises of whether to initiate prophylactic treatment. Potential candidates are those with a high recurrence risk and/or concern about the recurrence of a severe episode. Research has shown that most patients can be stabilized, with selected monotherapy individualized on the basis of the nature of the clinical course (episodic vs. non-episodic), quality of the spontaneous remission, and family history of psychiatric disorders and treatment response.Novel adjunctive treatments including nutraceuticals, antioxidants, and anti-inflammatory agents are being studied and may be helpful in high-risk individuals during the early stages of illness development.

Ethical considerations in preventive interventions for bipolar disorder

“…Antidepressants have been noted to have poor efficacy and greater risk of negative outcomes including manic symptoms and suicidality as outlined previously. A review of stage‐specific treatment options recommends avoiding antidepressants or mood stabilizers for those without clear major mood episodes . The treatment of established depressive episodes among those with high familial risk is more complicated.…”

“…A review of stage-specific treatment options recommends avoiding antidepressants or mood stabilizers for those without clear major mood episodes. 67 The treatment of established depressive episodes among those with high familial risk is more complicated. For persons with particularly severe depressive episodes or those that are not responsive to psychological interventions, a short trial of an antidepressant may be warranted with an informed discussion on the benefits and risks of such medications.…”

A Multi-Dimensional and Integrative Approach to Examining the High-Risk and Ultra-High-Risk Stages of Bipolar Disorder

“…More importantly, identifying abnormalities prior to full-blown onset opens up the possibility of putting into practice early intervention (i.e., when cognitive deficits are observed in the UHR stage) or even primary intervention strategies (i.e., when intact cognitive function but disrupted brain connections are observed in the HR stage), of particular importance because BP is currently considered irremediable and becomes progressively worse. A range of early interventions that show preliminary evidence of effectiveness, including sleep hygiene, nutraceuticals (e.g., omega-3 fatty acids), mindfulness, emotion regulation strategies, and anti-inflammatory agents ( Duffy, 2014a ), might be justified for offspring at familiar risk and those in the UHR stage in particular.…”

Early intervention in bipolar disorders: Where we are now and need to go next

“…At this point, there are certainly more questions than answers when it comes to early intervention in bipolar disorders; however, there is an accruing base of informative evidence on which we can build . More collaborative international longitudinal research in well‐characterized high‐risk cohorts is needed moving forward.…”