Bipolar disorder is one of the most misunderstood mental health conditions. Bipolar disorder involves the experience of intense mood episodes that may alternate between emotional highs and lows (mania and depression). An estimated 4.4% of U.S. adults experience bipolar disorder at some time in their lives; however bipolar disorder can occur at any age. An estimated 82.9% of people with bipolar disorder experienced serious impairment, the highest percent serious impairment among mood disorders.
At UIC, specialized clinics have been developed to assess and treat bipolar spectrum disorders in pediatric, adult, and geriatric populations using evidence-based, research-informed approaches: the Pediatric Mood Disorders Clinic and the Adult Bipolar Clinic. In this article, UICDR members from each of these clinics share their expertise to increase understanding of bipolar spectrum disorders across the lifespan.
Signs and Symptoms
Bipolar disorder is considered a spectrum, with different diagnoses depending on the nature and severity of symptoms. There are three types of bipolar disorder. All three types involve clear changes in mood, energy, and activity levels. These moods range from periods of extremely “up,” elated, irritable, or energized behavior (known as manic episodes) to very “down,” sad, indifferent, or hopeless periods (known as depressive episodes). Less severe manic periods are known as hypomanic episodes.
- Bipolar I Disorder— defined by manic episodes that last at least 7 days, or by manic symptoms that are so severe that the person needs immediate hospital care. Usually, depressive episodes occur as well, typically lasting at least 2 weeks.
- Bipolar II Disorder— defined by a pattern of depressive episodes and hypomanic episodes, but not the full-blown manic episodes that are typical of Bipolar I Disorder.
- Cyclothymic Disorder (also called Cyclothymia)—defined by periods of hypomanic symptoms as well as periods of depressive symptoms lasting for at least 2 years. However, the symptoms do not meet the diagnostic requirements for a hypomanic episode and a depressive episode.
Sometimes a person might experience symptoms of bipolar disorder that do not match the three categories listed above, which is referred to as “other specified and unspecified bipolar and related disorders."*
Symptoms of bipolar disorder in children often may present differently from adult populations. As a result, it may be difficult to recognize and correctly diagnose bipolar disorder in this population. In older adults with this condition however, symptoms can additionally comprise cognitive deficits that sometimes overlap with those of a neurodegenerative process.
Bipolar disorder in children and adolescents
Bipolar disorder was historically considered to be an adult disease. It had been thought to onset in early adulthood, and believed to be extremely rare or non-existent in children. However, recent large epidemiological studies in youth ages 5 and older, across the world, indicate that the prevalence rate of bipolar spectrum disorders in children/adolescents is 1-2%. This rate is similar to the adult prevalence rate. To put this rate in context, bipolar disorders in youth are more common than autism and schizophrenia, and less common than depression and attention deficit hyperactivity disorder (ADHD).
Children with bipolar disorder exhibit distinct episodes of mania and depression and often a combination of both concurrently. “Research suggests that the experience of episodes – discrete onsets and offsets to mood and associated symptoms – is key to differentiating bipolar disorders in youth from other disorders that share overlapping features (e.g., ADHD) ,” said Sally Weinstein PhD, Associate Director of the UICDR and Associate Professor of Clinical Psychology, UIC College of Medicine, and Director of Psychosocial Training in the Pediatric Mood Disorders Clinic. Mania includes the experience of elation or irritability in addition to 3-4 associated symptoms (eg., grandiosity, increased goal-directed activity, excessive risk-taking/pleasurable activities/hypersexuality, distractibility, decreased need for sleep, flight of ideas, and pressured speech). Depression includes the experience of sadness or loss of pleasure, accompanied by symptoms of appetite changes, sleep changes, psychomotor agitation or retardation, fatigue/loss of energy, feelings of worthlessness or guilt, diminished concentration, and/or thoughts of death.
Although bipolar disorder symptoms are the same as those seen in adulthood, there is some evidence that there are unique features of bipolar disorders that onset in children versus later adolescence/adulthood – including greater prominence of irritability/rage, more frequent cycling between mood states within mood episodes, and greater heterogeneity of clinical features. Symptoms in childhood may look different and are manifested more developmentally. For instance, grandiosity may be seen through challenging of teachers or authorities, and creativity by engaging in many after school activities, and can be detected by parents and others in the child’s life rather than reported by the child/adolescent themself.
Diagnosis and treatment for children with bipolar disorder
Bipolar disorder is challenging to diagnose in youth because many of the features are difficult to distinguish from developmentally-appropriate emotions and behaviors, such as increased energy, irritability, changes in sleep.
Thorough, accurate diagnosis of bipolar spectrum disorders in pediatric populations takes time, careful monitoring of symptoms, and consideration of family history given the course and nature of BD in youth. Expert consensus on the assessment of pediatric bipolar disorder outlines 6 key steps:
- A timeline or comprehensive developmental history because the disorder is episodic in nature
- A structured/comprehensive interview to rule out differential diagnosis, as there are many overlapping features of other diagnoses (ADHD, PTSD) in youth
- Arguably the most important – is constructing a 3-generation family history to understand the family and evaluate the occurrence of pathology given the heritability of the disorder
- A symptom rating scale of severity, to track progress across treatment (e.g., the Child Mania Rating Scale, which was developed in the UIC Department of Psychiatry’s Pediatric Mood Disorders Clinic and has shown high reliability and validity for identifying pediatric mania)
- A global rating of functioning, as bipolar disorder impacts numerous psychosocial domains
- The ongoing completion of mood logs to monitor and track symptom presentation and results of treatment
Additionally, assessing family history of bipolar and mood disorders is critical – research suggests that the presence of mania symptoms in the absence of a family history does not distinguish between youth with a documented bipolar diagnosis from those without a bipolar diagnosis – and thus will lead to false prediction to rely on symptoms only.
“We know that the earlier intervention for children adolescents and their families, the better the outcomes for all” said Julie Carbray PhD, Director of the Pediatric Mood Disorders Program and Clinical Professor of Psychiatry, UIC College of Medicine. “Our family approach addresses the entire family system, as our team has demonstrated that a family approach is critical”. Untreated, bipolar disorder results in devastating consequences for the youth and family. Among youth with bipolar disorder we see lower rates of graduation, higher rates of substance use, and greater risk for suicidality – with risk for, and mortality from, suicide exceeding that of any other childhood psychiatric disorder. However, with early assessment and intervention these outcomes can be prevented; we see high rates of recovery from episodes and positive global functioning among youth who have received appropriate treatment for bipolar disorder.
For more information about evidence-based intervention approaches for bipolar disorder in pediatric populations that have been developed by UICDR members, go to https://uifightdepression.psych.uic.edu/pioneering-research/behavioral-therapy-for-pediatric-bipolar-disorder
Bipolar disorder in adults and older adults
According to the National Institute of Mental Health, bipolar disorder affects approximately 2.6 percent of the U.S. adult population in a given year, or about 5.7 million American adults.
The prevalence rates for older adults are lower than for younger patients due to increased mortality rates, which is estimated around 0.25%. However, according to some studies, geriatric bipolar disorder may represent up to 19% of inpatient admissions to geriatric psychiatry units.
Symptoms of bipolar in older adults are the for the most part the same as in younger patients. However, in older adults, you tend to see more of the following:
- Longer latency between depression and mania
- More likely to relapse into depression after mania
- Decreased suicide rates (may be survivor effect)
- Less co-morbid substance abuse
- More co-morbid cognitive disorders and medical issues
Clearing up misconceptions about Bipolar disorder
Misconceptions about bipolar disorder abound, and may act as a barrier to proper treatment and limiting support, as well as stigmatizing the condition.
One of the biggest myths is that bipolar disorders cannot be diagnosed in pediatric populations – but research over the past 20 years has shown that bipolar disorder is a reliable, valid diagnosis in youth with prevalence rates that approximate those in adults.
Another myth, and source of much controversy, is that rates of bipolar disorder are higher in the US, and increasing in youth. This is supported by billing/services data that show a 40-fold increase in rates of diagnoses in pediatric populations in the US over a 20-year period. However, these data are misleading – and driven by differences in training, conceptualization of bipolar disorder in youth, and insurance demands rather than changes in prevalence over time. Research supports that rates of bipolar disorder in the US are similar to those found worldwide.
A common misconception about adults with bipolar disorder is the belief that just because a person we know appears somewhat scattered with “highs” and “lows” on a particular day, they must be having a bipolar or “manic” moment. “That it is never possible, nor responsible, to diagnose a person based on a snap-shot presentation. Human brains are highly complex biological computers and more. While some people may have a bipolar condition, we are all human beings who are a lot more than the medical conditions we may have”, said Alex Leow MD, PhD member of the UICDR and Associate Professor in UIC’s Department of Psychiatry.
One of the common myths about older adults with bipolar disorder is that bipolar disorder “burns out” over time and “mellows” with age. However, evidence suggests that the mood episodes in bipolar disorder become more severe with age and actually occur more frequently over time. Older patients with bipolar disorder are more likely have to serious medical co-morbidities that contribute to higher rates of mortality. Attention to physical well-being is of vital importance in this population.
Bipolar disorder is a lifelong condition; with ongoing comprehensive effective treatment individuals can be empowered with the ability to manage their mood swings and other symptoms, enabling them to live a healthy life.
Explore more of the pioneering bipolar disorder research and cutting-edge treatment at UIC clinics:
Pediatric Mood Disorders Clinic
The Pediatric Mood Disorders Clinic is a nationally recognized program in the diagnosis and treatment of children and adolescents with mood disorders and their comorbid conditions. Our treatment team works to provide evidence based treatments for children and their families affected by mood disorders. This includes state of the art treatment with medication, and Cognitive behavior therapy focused group and family treatment, originally developed, tested and established in our program. Our approach is to collaborate with diverse schools and families building upon family strengths as they navigate their way to health. The clinic provides specialized training for child psychiatrists, medical students, psychiatric nurses, psychologists and social workers in the specialty of pediatric mood disorders. To request an appointment, please call 312.996.7723.
https://www.psych.uic.edu/clinical/child-and-adolescent-services/pediatric-mood-disorders-clinic
Julie A. Carbray PhD PMHNP-BC PMHCNS-BC APRN
Director, Pediatric Mood Disorders Clinic
Clinical Professor of Psychiatry and Nursing
Sally Weinstein PhD
Licensed Clinical Psychologist, Director of Psychosocial Training, Pediatric Mood Disorders Clinic
Associate Professor of Clinical Psychology in Psychiatry
Mathias James LilligMedical Director, Pediatric Mood Disorders Clinic
Assistant Professor of Psychiatry
Adult Bipolar Clinic
Directed by Dr. Alex Leow and staffed by senior residents under the supervision of both Dr. Leow and Dr. John Zulueta, the UIC Bipolar Outpatient Clinic provides adults with bipolar disorders a range of treatment options. Treatment decisions are collaborative and tailored to individual patients' needs. Compassion, competence and respect for every patient are the hallmarks of our program. To request an appointment, please call 312.996.2200.
Alex Leow MD PhD
Associate Professor in Psychiatry and Bioengineering
John Zulueta MD
Assistant Professor of Clinical Psychiatry
* The National Institute of Mental Health