The morbidity of subthreshold pediatric bipolar disorder: A systematic literature review and meta‐analysis

Abstract

Objective: The objective of this study was to evaluate the morbidity of subthreshold pediatric bipolar (BP) disorder. Methods:We performed a systematic literature search in November 2017 and included studies examining the morbidity of pediatric subthreshold BP. Extracted outcomes included functional impairment, severity of mood symptoms, psychiatric comorbidities, suicidal ideation and behaviors, and mental health treatment. We used meta-analysis to compute the pooled standardized mean difference (SMD) for continuous measures and the pooled risk ratio (RR) for binary measures between two paired groups: subthreshold pediatric BP vs controls and subthreshold pediatric BP vs pediatric BP-I. Results: Eleven papers, consisting of seven datasets, were included. We compared subthreshold pediatric BP (N = 244) to non-BP controls (N = 1125) and subthreshold pediatric BP (N = 643) to pediatric BP-I (N = 942). Subthreshold pediatric BP was associated with greater functional impairment (SMD = 0.61, CI 0.25-0.97), greater severity of mood symptomatology (mania: SMD = 1.88, CI 1.38-2.38; depression: SMD = 0.66, CI 0.52-0.80), higher rates of disruptive behavior (RR = 1.75, CI 1.17-2.62), mood (RR = 1.78, CI 1.29-2.79) and substance use (RR = 2.27, CI 1.23-4.21)disorders, and higher rates of suicidal ideation and attempts (RR = 7.66, CI 1.71-34.33) compared to controls. Pediatric BP-I was associated with greater functional impairment, greater severity of manic symptoms, higher rates of suicidal ideation and attempts, and higher rates of mental health treatment compared to subthreshold pediatric BP. There were no differences between full and subthreshold cases in the severity of depressive symptoms or rates of comorbid disorders.Conclusions: Subthreshold pediatric BP disorder is an identifiable morbid condition associated with significant functional impairment including psychiatric comorbidities and high rates of suicidality. K E Y W O R D Sbipolar disorder, child, pediatric, subthreshold | INTRODUC TI ONAs pediatric bipolar (BP) disorder tends to evolve over time, some youth may present to clinical attention with insufficient symptoms to fulfill full diagnostic criteria for a diagnosis of BP disorder.However, while much is known about full threshold pediatric BP disorder, little is known about subthreshold forms of pediatric BP disorder.

Can the Child Behavior Checklist (CBCL) help characterize the types of psychopathologic conditions driving child psychiatry referrals?

“…We examined the clinical profile of the entire group by calculating the percentage of subjects with scores in the clinical and subclinical range for each clinical scale of the CBCL. As previously reported, subthreshold scores are clinically meaningful (36,37). We performed two stratified analyses by sex and age and compared the profile of males versus females and patients ≤12 years of age versus patients >12 years of age using logistic and ordered logistic regression models depending on the distribution of the data.…”

The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders

“…Early-onset BD can occur in young adolescents but is rare in children. The unofficial term ‘paediatric bipolar disorder’ has been used to describe young people with classic episodic and severe mood fluctuation, but confusingly has also been applied to children with persistent and severe hyperactivity, impulsivity, affective dysregulation and explosive temper (Duffy et al, 2020; Vaudreuil et al, 2019). The case for the latter being a variant or subtype of BD is unproven and the reliable diagnosis of bipolar disorder in young children remains questionable (Malhi and Bell, 2020).…”

Further evidence of high level of persistence of pediatric bipolar-I disorder from childhood onto young adulthood: a five-year follow up

“…In addition, in the 4-year follow up, we report on the persistence of major depression, but in the 5-year follow up, we report on the persistence of depression by indicating rates of both full and subthreshold depression. As reported by Vaudreuil et al ( 10 ), subthreshold states of pediatric BP disorder are highly morbid in themselves and, if present, should not be considered remission. Few longitudinal studies of pediatric BP consider the persistence of full and subsyndromal mania as well as full and subsyndromal depression.…”

“…There were no significant differences in sex, ethnicity, age, or SES between those with syndromatic persistence, symptomatic persistence, and syndromatic and symptomatic remission (Table 1). [range] 11.5±3.6 [4][5][6][7][8][9][10][11][12][13][14][15][16] 9.2±3.5 [4][5][6][7][8][9][10][11][12][13][14][15][16][17] 9.3±3.4 [4][5][6][7][8][9][10][11][12][13][14][15][16][17] F(2, 65)=2.14 0.13 Age at follow-up [range ] 16.9±4.2 [9][10][11][12][13][14]…”