Preventative Strategies for Early-Onset Bipolar Disorder

Abstract

Bipolar disorder is a chronic and typically recurring illness with significant psychosocial morbidity. Although the aetiological factors that contribute to the onset of mania, and by definition bipolar I disorder, are poorly understood, it most commonly occurs during the adolescent period. Putative risk factors for developing bipolar disorder include having a first-degree relative with a mood disorder, physical/sexual abuse and other psychosocial stressors, substance use disorders, psychostimulant and antidepressant medication exposure and omega-3 fatty acid deficiency. Prominent prodromal clinical features include episodic symptoms of depression, anxiety, hypomania, anger/irritability and disturbances in sleep and attention. Because prodromal mood symptoms precede the onset of mania by an average of 10 years, and there is low specificity of risk factors and prodromal features for mania, interventions initiated prior to onset of the disorder (primary prevention) or early in the course of the disorder (early or secondary prevention) must be safe and well tolerated upon long-term exposure. Indeed, antidepressant and psychostimulant medications may precipitate the onset of mania. Although mood stabilizers and atypical antipsychotic medications exhibit efficacy in youth with bipolar I disorder, their efficacy for the treatment of prodromal mood symptoms is largely unknown. Moreover, mood stabilizers and atypical antipsychotics are associated with prohibitive treatment-emergent adverse effects. In contrast, omega-3 fatty acids have neurotrophic and neuroprotective properties and have been found to be efficacious, safe and well tolerated in the treatment of manic and depressive symptoms in children and adolescents. Together, extant evidence endorses a clinical staging model in which subjects at elevated risk for developing mania are treated with safer interventions (i.e. omega-3 fatty acids, family-focused therapy) in the prodromal phase, followed by pharmacological agents with potential adverse effects for nonresponsive cases and secondary prevention. This approach warrants evaluation in prospective longitudinal trials in youth determined to be at ultra-high risk for bipolar I disorder.

Staging of Mental Disorders: Systematic Review

“…This model was recently revised by McNamara et al [66]. The main difference is that only 3 stages were included; the unremitting/treatment-refractory course was not taken into account and the high-risk condition was placed at stage 1 rather than at stage 0, meaning that it is part of the illness.…”

“…There have been a number of suggestions as to stage-specific treatments [19,22,23,64,65,66,67]. A randomized controlled trial [73], confirmed by studies on psychoeducation [74], demonstrated the feasibility of early intervention aimed at recognizing prodromal symptomatology.…”

A Randomized Controlled Trial of Individual Family Psychoeducational Psychotherapy and Omega-3 Fatty Acids in Youth with Subsyndromal Bipolar Disorder

“…O3 may improve symptoms of many psychiatric disorders in youth including mood disorders (Wozniak et al 2007;Clayton et al 2009;McNamara et al 2010;Sarris et al 2012), autism (Amminger et al 2007), attention-deficit/hyperactivity disorder (ADHD) (Sinn and Bryan 2007;Sorgi et al 2007), and psychosis (Amminger et al 2010). O3 has also been shown to significantly improve cardiovascular and metabolic health and decrease body fat, both independently and in combination with regular exercise (Hill et al 2007).…”

“…Whereas combination treatment is also recommended for youth with BPSD (McClellan et al 2007;McNamara et al 2010), it has not been examined in children with BP-NOS/CYC in a controlled trial. Because of adverse effects with mood stabilizers, antipsychotics, antidepressants, and psychostimulants in pediatric BPSD, McNamara and colleagues have suggested that safer and well-tolerated interventions with demonstrated efficacy be used to treat prodromal/subsyndromal BPSD (McNamara et al 2010).…”

Staging bipolar disorder: Clinical framework, biomarkers and interventions

“…Iako se izvestan broj istraživača zalaže za primenu farmakoterapije u stanjima povišenog rizika za psihozu, a usled boljeg daljeg toka bolesti i smanjenja broja relapsa, ovakav terapijski pristup može biti neadekvatan kada se radi o BAP [71,74]. Naime, agresivan terapijski pristup i lečenje početnih, asimptomatskih stadijuma BAP može dovesti do narušenja adaptivnih osobina i karakerisitka temperamenta koje mogu biti i deo bolesti pa je u terapiji BAP posebno važno razmišljati o funkcionalnosti pacijenta, a ne o kompletnoj stabilizaciji raspoloženja [12].…”