Characteristics prior to and at time of diagnosis in pediatric bipolar disorder.

OBJECTIVES: Describe symptoms before and at time of register-diagnosis in children and adolescents. METHODS: A random sample was selected for chart-review from a Danish nationwide cohort of patients <18 years registered with an incident ICD-10 register-diagnosis of single hypomanic/manic episode or bipolar disorder between 1995 and 2014. Patients with symptoms which adequately documented a BD diagnosis in the chart were included for analysis. RESULTS: 521 were diagnosed in the study period. A random sample of 25% were selected, and 106 charts were possible to retrieve, with 48 chart reviews resulting in confirmation of diagnosis. Time from first reported affective symptoms to diagnosis was 2.6 ± 2.7 years for depressive symptoms, 2.5 ± 2.9 years for mixed symptoms, 1.4 ± 1.6 years for hypomanic symptoms, and 0.4 ± 0.5 years for manic symptoms. A hierarchical clustering analysis revealed three patient-profiles: primarily hypomanic/manic, primarily depressive, and more rare, primarily mixed profile. Frequently reported symptoms prior to diagnosis include anhedonia (79%), irritability (71%), hyperactivity (62.5%), decreased energy (62.5%), and psychotic symptoms (52%).Symptoms of ADHD (19%), comorbid ADHD (15%), symptoms of anxiety (52%), comorbid anxiety (4%), suicidal thoughts (50%), suicide attempts (8%), cutting (23%), substance misuse (21%), and criminal activity (10%) were reported before incident BD diagnosis. CONCLUSION: The observed patient-profiles leading to diagnosis were primarily manic or depressive, resembling presentations in adults. The presence of ADHD, anxiety, suicide attempts, cutting, and criminal activity prior to diagnosis emphasizes the need for treatment of children and adolescents with affective symptoms. The gap from appearance of the symptoms to diagnosis suggests a window for earlier treatment.

Longitudinal outcomes in pediatric- and adult-onset bipolar patients compared to healthy and schizophrenia controls.

OBJECTIVES: Comparing outcomes of bipolar disorder (BD) with schizophrenia (SCZ) and psychiatrically healthy controls (PHC), contrasting pediatric-onset with adult-onset disorders. METHODS: A nationwide cohort study, including patients with an incident diagnosis of BD or SCZ registered in the Danish National Patient Registry and corresponding PHCs. Outcomes were (a) duration of hospitalization, (b) psychiatric admissions, (c) psychiatric outpatient contacts, (d) bone-fracture-related healthcare contacts, (e) self-harm-related healthcare contacts (including suicide and non-suicidal self-injuries), and (f) criminal charges. Incidence rate ratios (IRRs), adjusted for age at first psychiatric contact, substance abuse and parental psychiatric illness, were calculated, comparing pediatric-onset BD (5-17 years) and adult-onset BD (18-39 years) with age- and sex-matched SCZ patients and PHC. RESULTS: Pediatric-onset BD (n = 349) performed better than 1:1-matched pediatric-onset SCZ (n = 349) on all six outcomes (IRR = 0.30 for self-harm-related contacts (P < 0.001) to IRR = 0.86 for criminal charges (P = 0.05). Similar, but less pronounced results were observed comparing 1:1-matched adult-onset BD (n = 5515) with adult-onset SCZ (n = 5515) IRR = 0.58 for psychiatric outpatient contact (P < 0.001) to IRR = 0.93 for criminal charges (P < 0.001), except for more bone-fracture-related contacts in adult-onset BD (IRR = 1.13, P < 0.01). Comparing pediatric-onset BD (n = 365) to 1:3-matched PHC (n = 1095), only self-harm-related contacts differed significantly (IRR = 2.80, P < 0.001). Conversely, comparing adult-onset BD (n = 6005) with 1:3-matched PHC (n = 18 015), self-harm-related contacts (IRR = 16.68, P < 0.001), bone fractures (IRR = 1.74, P < 0.001), and criminal charges (IRR = 2.03, P < 0.001) were more common in BD. CONCLUSION: BD was associated with poorer outcomes than PHC, but better outcomes than SCZ. Furthermore, outcomes were more favorable in pediatric-onset BD when indirectly contrasted to adult-onset BD.

Increasing mortality gap for patients diagnosed with bipolar disorder-A nationwide study with 20 years of follow-up.

OBJECTIVES: The primary aim of this study was to examine whether the mortality of patients with bipolar disorder has increased over the past two decades as compared with the background population. METHODS: All patients registered with a bipolar disorder diagnosis in the Danish Psychiatric Research Registry from 1965 until the end of 2014, living in Denmark, alive and below the age of 65 years in the study period from 1995 to 2014 were included. Included patients reaching the age of 65 years during the study period were censored at that time point. Overall standardized mortality ratios (SMRs) were calculated for each calendar year over the study period, and trends in SMR over the study period were examined using linear regression. In addition, the SMRs were stratified according to age groups. RESULTS: Patients with bipolar disorder had an overall elevated mortality rate relative to the general population with an SMR of 2.8, 95% confidence interval (CI): 2.8-2.9. The highest SMR was found among the youngest (15-29 years: 8.2, 95% CI: 6.7-10.1; 30-34 years: 7.7, 95% CI: 6.4-9.3; 35-39 years: 6.2, 95% CI: 5.4-7.2; 40-44 years: 4.6, 95% CI: 4.1-5.1; 45-49 years: 3.5, 95% CI: 3.3-3.8; 50-54 years: 3.2, 95% CI: 3.0-3.4; 55-59 years: 2.7, 95% CI: 2.6-2.8; and 60-64 years: 2.2, 95% CI: 2.1-2.3). An increase in SMR of 0.03 per year in patients diagnosed with bipolar disorder (P < 0.01) was found. CONCLUSIONS: The mortality gap between patients with bipolar disorder and the general Danish population has widened over the past two decades, which is a cause for concern, although reasons for the increasing mortality gap are unknown.