Course and Outcome of Bipolar Youth
This study is no longer recruiting.
COBY enrolled 436 participants, ages 7-17 across its 3 study sites at UPMC, UCLA and Brown University. Some of the participants had a diagnosis of Bipolar Disorder-I (BP-I), or Bipolar Disorder-II (BP-II), and some had sub-clinical symptoms (not the full disorder) a condition usually called Bipolar Disorder Not Otherwise Specified (BP-NOS). These children and teens with BP-NOS had most symptoms of mania but did not have the required duration to be diagnosed as bipolar disorder type I or II. However, some of these children and teens, especially those with bipolar disorder in their families, went on to develop full Bipolar Disorder (I or II). Moreover, youth with BP-NOS had symptoms that negatively affected their ability to function (e.g., at school, in relationships), risk for suicidal thoughts and behaviors, and risk for substance use similar those youth diagnosed with BP-I or BP-II.
Almost all youth, at study entry and during the follow-up, had other disorders in addition to bipolar disorder such as anxiety disorders, Attention Deficit Hyperactive Disorder (ADHD) and behavioral disorders. The presence of these disorders affected their functioning beyond the negative effects of the bipolar disorder.
One of the main goals of the COBY study was to find out what happened to these children and teens over time. We found that over a period of 4 years, about 80% of them recovered from the initial mood episode but a portion of them continued to have manic or depressive symptoms (or both). As we continued to follow the youth who were doing well, about 62% had a mood recurrence, particularly depressions. Those who were at higher risk to have recurrences were: 1) those who had more prior mood episodes, 2) those who had longer and more severe episodes of mania or depression; 3) those who had co-occurring disorders like anxiety or ADHD, 4) those with a history of being physically or sexually abused, 5) those whose family members had psychiatric disorders, and 5) those with more difficulties functioning and more stressful home environments.
Importantly, we also found that about 25% of the children and teens in the study did well over time and did not have recurrences of mania or hypomania, and if they did, the episode was short and with mild symptoms; several no longer required treatment with medications to maintain mood stability. This finding is particularly important because in the past, it was thought that all people with bipolar disorder required life-long medication treatment.
We already know that a significant proportion of youth with bipolar disorder experience recurrences and that there are specific factors that increase the risk for these recurrences. However, this information is for the group as a whole and not for a specific individual. To improve our ability to predict an individual patient’s illness course, COBY has developed a “Risk Calculator”, a mathematical model, to predict an individual’s likelihood of having a recurrence of a manic or depressive episode. This approach has been used in other fields of Medicine (for example, to predict an individual patient’s risk of having a heart attack or developing diabetes). The accuracy of the risk calculator we developed to predict recurrence risk for youth with bipolar disorder is about 80%, which is better than most risk calculators in Medicine (e.g., to predict heart attacks and cancer). In the future, this risk calculator may be integrated into clinic visits to personalize treatment for patients with bipolar disorder.
At study entry and during the follow-up, about 50% of the participants had a history of suicidal ideation or suicide attempts. A significant proportion of the suicidal ideation and attempts occurred during the follow-up, suggesting that there is a window of opportunity to treat these youth to prevent the onset of suicidal behaviors. Youth who were at higher risk to have suicidal thoughts or suicide attempts were the ones who had more severe depressions, abused substances, and had other psychiatric disorders, in addition to bipolar disorder. Of note, COBY found that of all medications used to treat bipolar disorder, lithium was the only one that reduced the risk for suicide attempts.
At the beginning of the study, very few of the children and adolescents enrolled in COBY were misusing or abusing substances. However, over time, up to 40% of participants developed substance use disorders, particularly marijuana and alcohol. Youth who developed substance use disorders were those whose manic or depressive symptoms were not under control, those with other psychiatric conditions such as ADHD, and those with a family history of substance use disorders. The fact that many COBY participants developed substance use disorders during the follow-up tells us that offering a substance abuse prevention program for teens or young adults with bipolar disorder could be beneficial.
At study entry, about 20% of COBY participants had metabolic syndrome, a condition manifested by being overweight and having high cholesterol, and high blood levels of glucose; this is more than twice the rate of metabolic syndrome in the general population. In many cases, weight gain and metabolic syndrome are side-effects of medications used to treat mood symptoms. Since metabolic syndrome and overweight increase the risk of myocardial infarction and other physical and mental problems, such as low self-esteem, management of bipolar disorder should integrate strategies focused on preventing metabolic syndrome.
Finally, COBY also found that many of the participants had significant problems with school, work, and interpersonal and family relationships. Some of them also had legal difficulties. However, when their mood and other psychiatric disorders improved, their functioning in the areas noted above also got better. These data clearly show the direct impact that mood symptoms can have on all aspects of an individual’s life and the potential for substantial improvement in well-being and functioning when mood symptoms are adequately controlled.
Conclusion:
As you can see, the wealth of data we have collected over these years in COBY has enabled us to answer critical questions about early-onset bipolar disorder. We will continue to work tirelessly to share all that we have learned with other families and professionals across the country and the world to ensure that other youth diagnosed with bipolar disorder receive the best possible information, education, and treatments available to them. None of this would be possible without the participation of our dedicated COBY participants and families!
Further Reading
Phenomenology of Children and Adolescents With Bipolar Spectrum Disorders Axelson D., et al 2006
Clinical Course of Children and Adolescents With Bipolar Spectrum Disorders Birmaher B., et al 2006
Substance use disorders among adolescents with bipolar spectrum disorders Goldstein B., et al 2008
For a PDF list of all associated publications: Click here