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Lead author Melissa P. DelBello, MD, from the University of Cincinnati College of Medicine, Ohio, told Medscape: "It's the first study to look at different types of outcome. Studies in the past looked at syndromic outcome, and that's pretty good, but it doesn't tell you the whole story." She added that their study showed that even though patients may no longer technically meet the syndromic "picture" of an affective episode, a significant and permanent level of impairment remained after an initial bipolar episode. In addition, "full adherence" to medication, which was defined as taking medication as prescribed more than 75% of the time, was absent in 65% of the patients. She observed: "[Patients] really need to be at least 75% adherent to [their] medication, since any less than that negatively impacts outcome."

The group defined "syndromic recovery" as no longer meeting the full Diagnostic and Statistical Manual of Mental Disorders IV criteria for having an affective bipolar episode. "Symptomatic recovery" was defined as having no symptoms or only 1 or more mild symptoms. "Functional recovery" was defined as having psychosocial functions at least as good as before the affective bipolar episode.

They explain that the onset of bipolar disorder most commonly occurs in adolescence and is associated with significant morbidity, but there have been few prospective outcome studies of this population. The primary aim of this study was to investigate the 12-month outcomes of bipolar adolescents following their initial hospitalization for a manic or mixed episode. The secondary aim was to examine whether there are distinct predictors of syndromic, symptomatic, and functional outcomes.

They recruited 71 consecutive adolescents with bipolar disorder, aged 12 to 18 years, who were admitted at a single center for their first hospitalization for a manic or mixed episode.

Frequent Lack of Full Functional Recovery

Most of the adolescents (85%) experienced syndromic recovery at an average of 20 weeks after their initial hospitalization, but fewer experienced symptomatic or functional recovery. Only 20% experienced all 3 types of recovery. More than half of the patients had a recurrent episode of bipolar disorder, at about 17 weeks after their initial hospitalization.

Outcomes in Adolescents Following First Hospitalization for Bipolar Disorder

Outcome
Participants (n)
Participants (%)
Time, Weeks (Mean ± SD)
Syndromic recovery
60/71
85
20 ± 13*
Symptomatic recovery
28/71
39
35 ± 13*
Functional recovery
28/71
39
38 ± 16*
Syndromic recurrence
31/60
52
17 ± 11
*Following initial hospitalization.
†Following syndromic recovery.

During the year following their initial hospitalization for bipolar disorder, the patients experienced an affective episode (mostly a mixed episode) 38% of the time and had subsyndromal symptoms 46% of the time; they were asymptomatic only 16% of the time.

Coincident anxiety disorders, disruptive behavior disorders, attention deficit hyperactivity disorder (ADHD), and medication nonadherence were associated with lower rates of syndromic recovery; the latter 2 factors as well as lower socioeconomic status were also linked a longer time to syndromic recovery. Alcohol-use disorders and lack of psychotherapeutic intervention following hospitalization were linked with syndromic recurrence; both factors as well as antidepressant treatment were linked with a shorter time to syndromic recurrence. Medication nonadherence rate was associated with concomitant ADHD, alcohol-use disorders, and low socioeconomic status.

It's very important to look at how well adolescent bipolar patients are living their daily lives, in addition to looking at their symptoms, Dr. DelBello said. To improve outcomes, "we need to aggressively treat this disorder, to better understand treatments for bipolar patients with co-occurring disorders, and to start doing something preventive." She added that more studies are needed to determine how to prevent substance use and poor treatment adherence in bipolar adolescents.

Need to Treat Subsyndromal Symptoms

Boris Birmaher, MD, from the University of Pittsburgh Medical Center, in Pennsylvania, who wrote an editorial that accompanies the article, told Medscape that the main messages are that bipolar disorder exists in children and is recurrent. It affects the psychosocial development of the child and increases the risk for suicide, legal problems, and other psychiatric disorders, unless it is recognized and treated. He added that this study confirms and extends prior findings that children and adolescents with bipolar disorder not only experience syndromal recurrences but, during their follow-up, have subsyndromal symptoms that significantly affect their functioning.

The clinical implications are to first recognize the illness and then "treat these adolescents completely and not leave them with subsyndromal symptoms." Clinicians need to manage the subsyndromal symptoms very well, because adolescents with these symptoms have a high risk for recurrent episodes, he added, noting that successful treatment of comorbid disorders (such as alcohol use) may improve adherence to treatment.
 

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