Discussion
The main findings of our study are the high rate of recovery from the index episode and a significant improvement in global functioning. Another important finding is that those who had past episodes tended to have significantly longer index episodes. The findings of a high recovery rate contrast with those of some recent studies (3,5,6) and some older studies (4), which report low rates of recovery and high rates of chronicity. However, our finding accords with high recovery rates reported in some studies, including a previous study from the same centre (1,2). In our current sample, the mean YMRS score at intake was 39, which was higher than the score of 28 reported in a previous study (12); this indicates that our sample had severe manic symptomatology. There are 3 possible explanations for the better outcome in our sample. First, most of our sample were drug-naive at intake, unlike samples in previous studies (3,6). Further, our sample was self-referred; used the centre as a first-contact, primary clinical service; and entered the study relatively early in the episode. It is possible that patients seen in larger referral centres may be suffering from chronic forms of illness and from multiple comorbid conditions, resulting in ascertainment bias (13). It is also possible that patients in whom early intervention is carried out tend to have a better prognosis. Second, the low comorbidity rate (36%) could have contributed to the high recovery rate. Comorbid ADHD has been reported to be associated with poor recovery (3). In our sample, ADHD was comorbid in only 4%, which is very low, compared with the high rates reported previously (12,14,15). Comorbid conduct disorder and comorbid oppositional defiant disorder were present in 4% and 28%, respectively. This was similar to comorbidity reported in a previous study (12) and much lower than that reported in other studies (11,14,15). Third, our sample consisted mainly of adolescents, whereas other studies included a predominantly prepubertal population (3,6,15). That adolescents may have better recovery rates is further supported by the findings of other studies with predominantly adolescent samples (1,2). Finally, whether these findings reflect true cross-cultural differences in the outcome of juvenile BD needs further exploration.
The findings of our study have to be interpreted with certain limitations in mind. The sample size was small and not controlled for medication. In addition, the rater was not blind to the patients’ baseline clinical and medication status.
However, the findings of our study have important clinical and research implications. That most of our patients recovered within a short-term period of intensive treatment highlights the importance of aggressive pharmacologic intervention for patients with juvenile BD. The difference in sample characteristics—especially the relatively low rates of comorbidity—and the early institution of treatment may have been a major contributing factor. Second, our findings confirm a previous report from our centre that recovery rates are high (2), which raises the possibility of cross-cultural variation in outcome. This observation has to be understood in the context of favorable prognosis reported for schizophrenia among adults from developing countries, compared with adults from developed countries (16). It is therefore imperative to examine the course of juvenile BD in larger samples prospectively to confirm whether these variations are truly cross-cultural or the result of different ascertainment methods and sample characteristics.
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Table 2 YMRSa and CGASb scores over the course of the study period
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Scoresc
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At intake
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At 3 months
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At 6 months
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RMANOVAd
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|
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F-ratio
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P
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YMRS, mean (SD)
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39.2 (7.5)
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5.1 (7.5)
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3.0 (7.3)
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164.2
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< 0.0001
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CGAS, mean (SD)
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23.2 (9.3)
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73.9 (17.7)
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82.0 (15.1)
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140.9
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< 0.0001
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aYoung Mania Rating Scale (10)
bChildren’s Global Assessment Scale (11)
cAt
the 3-month rating, 3 patients had a fresh episode. At the 6-month rating,
there were 2 such patients. These were not considered for computing the
YMRS and CGAS scores.
RMANOVAd = Repeated Measures Analysis of Variance
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References
1. Strober M, Schmidt LS, Freeman R, Bower S, Lampert C, DeAntonio M. Recovery and relapse in adolescents with bipolar affective illness: a five-year naturalistic prospective follow up. J Am Acad Child Adolesc Psychiatry 1995;34:724–31.
2. Srinath S, Reddy JYC, Girimaji SR, Seshadri SP, Subbakrishna DK. A prospective study of bipolar disorder in children and adolescents from India. Acta Psychiatr Scand 1998;98 437–42.
3. Biederman J, Mick E, Bostic JQ, Prince J, Daly J, Wilens TE, and others. The naturalistic course of pharmacologic treatment of children with manic-like symptoms: a systematic chart review. J Clin Psychiatry 1998;59:628–37.
4. De Long GR, Aldershof AL. Long-term experience with lithium treatment in childhood: correlation with clinical diagnosis. J Am Acad Child Adolesc Psychiatry 1987;26:389–94.
5. Geller B, Zimerman B, William M, Bolhofner K, Craney JL, Delbello MP, and others. Six-month stability and outcome of a prepubertal and early onset bipolar disorder phenotype. J Child Adolesc Psychopharmacol 2000;10:165–73.
6. Geller B, Craney JL, Bolhofner K, Delbello MP, William M, Zimerman B. One- year recovery and relapse rates of children with a prepubertal and early onset bipolar disorder phenotype. Am J Psychiatry 2001;158:303–5.
7. Srinath S, Bharath S, Girimaji S, Seshadri SP. Characteristics of a child inpatient population with hysteria in India. J Am Acad Child Adolesc Psychiatry 1993;32:822–5.
8. Herjanic B, Reich W. Development of a structural interview for children: agreement between parent and child on individual symptoms. J Abnorm Child Psychol 1982;10:307–24.
9. Young RC, Biggs JT, Zeigler VE, Meyer DA. A rating scale for mania: reliability, validity and sensitivity. Br J Psychiatry 1978;133:429–35.
10. Shaffer D, Gould SM, Brasic J, Bird H, Fisher P. A children’s global assessment scale (C-GAS). Arch Gen Psychiatry 1983;40:1228–31.
11. Kovacs M, Pollock M. Bipolar disorder and comorbid conduct disorder in childhood and adolescents. J Am Acad Child Adolesc Psychiatry 1995;34:715–23.
12. Kafantaris V, Coletti DJ, Dicker R, Padula G, Pollack S. Are childhood psychiatric histories of bipolar adolescents associated with family history, psychosis and response to lithium treatment? J Affect Disord 1998;51:153–64.
13. Reddy YCJ, Srinath S. Juvenile bipolar disorder. Acta Psychiatr Scand 2000;102:162–70.
14. Wozniak J, Biederman J, Keily K, Ablon S, Faraone S, Mundy E, and others. Mania-like symptoms suggestive of childhood onset bipolar disorder in clinically referred children. J Am Acad Child Adolesc Psychiatry 1995;34:867–76.
15. Biederman J, Faraone SV, Chu MP, Wozniak J. Further evidence of a bi-directional overlap between juvenile mania and conduct disorder in children. J Am Acad Child Adolesc Psychiatry 1999;38:468–76.
16. Jablensky A. Epidemiology of schizophrenia. In: Gelder GM, Lopes-Ibor JJ, Andreasen N, editors. The new Oxford textbook of psychiatry. Oxford University Press; 2000. p 585–99.
Author(s)
Manuscript received March 2002, revised, and accepted October 2002.
1. Senior Resident, Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.
2. Professor, Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.
3. Associate Professor, Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.
4. Assistant Professor, Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.
5. Additional Professor, Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.
6. Additional Professor, Department of Biostatistics, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.
Address for correspondence: Dr S Srinath, Department of Psychiatry, PO Box 2900, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore 560 029, India.
e-mail: shobas@nimhans.kar.nic.in
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