Bipolar disorder in children and adolescents: obstacles to early diagnosis and future directions

Aim: This article reviews research centred around juvenile bipolar disorder with particular reference to diagnostic difficulties. Putative deficits are scrutinized with respect to trait likelihood and the roles of neuropsychology and neuroimaging in enhancing our understanding of juvenile bipolar disorder are discussed. Methods: Search terms including childhood, adolescent, youth and juvenile combined with the terms ‘bipolar disorder’, mania, depression and hypomania were used to identify relevant studies in MEDLINE and PsychLit. Results: Over recent years research into this relatively new disorder has increased phenomenally. Key issues within the field include diagnostic specificity, the heritability of the disorder, the impact of comorbidity and the implications of neuropsychological and neuroimaging findings. Conclusion: Despite concerning controversies in literature the diagnosis of bipolar disorder in children and adolescents as compared with adults, promising future research directions include better neurological characterization of the disorder through the application of findings from clinical populations, neuropsychological and neuroimaging research.     

The index manic episode in juvenile-onset bipolar disorder: the pattern of recovery.

OBJECTIVE: Recent studies of patients with juvenile bipolar disorder report low rates of recovery and high rates of chronicity. However, we lack data on the short-term outcome. This study examines the pattern of recovery from the index episode in an aggressively treated juvenile sample. METHOD: We assessed 25 subjects (< 16 years) with a diagnosis of mania, using the Diagnostic Interview for Children and Adolescents-Revised) (DICA-R), Young Mania Rating Scale (YMRS), and Children's Global Assessment Scale (CGAS) at intake and at 3 and 6 months. We studied the time taken to recover from the index episode, the level of functioning, and the factors predicting them. RESULTS: After 6 months, 24 (96%) subjects had recovered from the index manic episode. The median time to recovery was 27 days. Total episode length was significantly longer among those with previous affective episodes. CONCLUSIONS: The findings suggest that juvenile-onset mania has high rates of recovery and low rates of chronicity. These differences from the existing literature need further exploration.     

Interferon-induced depressive illness in hep C patients responds to SSRI antidepressant treatments

This paper examines the role of selective serotonin reuptake inhibitors (SSRIs) in the treatment of hepatitis-C virus (HCV) patients who have developed interferon-α induced depression. A 2-year data analysis of HCV psychiatric liaison clinic has been undertaken. The diagnosis, treatment, and progress of those patients who were treated with interferon-α (INF-α) are reported. 53 of the 78 patients enrolled at the HCV Clinic and treated with INF-α were referred for psychiatric consultation. Six patients developed major depressive illness following INF therapy. They were all treated with SSRIs and they made full recovery. This is a significant observation and is concordant with other studies. Its biochemical ramifications are presented. It is concluded that INF-induced depression is fully reversible. A hypothesis is proposed that SSRIs modulate the neuro-protective neurotoxic ratio by possibly inhibiting the indole-2,3-dioxygenase induction of the kynurenine pathway.     

Resolution of peripheral artery catheter-induced ischemic injury following prolonged treatment with topical nitroglycerin ointment in a newborn: a case report.

Tissue ischemia, necrosis, and gangrene are uncommon but well-described complications of arterial catheterization in the neonate. Treatment options for progressive tissue necrosis following arterial embolization and/or vasospasm are limited in these patients secondary to unpredictable pharmacokinetics and risks associated with systemic anticoagulation or vasodilatation in newborns. We report a case of a multidose regimen of topical 2% nitroglycerin ointment for reversing severe tissue ischemia following peripheral arterial line placement. The favorable response in this infant suggests that topical nitroglycerin therapy should be considered as potential therapy to ameliorate the effects of vascular compromise following arterial line placement in neonates.     

Synthesis of Diene‐Functionalized Macromonomers via Functionalization with Hexa‐1,3,5‐triene

The reaction of poly(styryl)lithium (PSLi) with hexa‐1,3,5‐triene (HXT) was studied as a route to diene‐functionalized macromonomers. When PSLi was reacted with 1.5 molar equivalents of HXT for 2.5 h at ?10 °C in toluene, it was found that the diene‐functionalized macromonomer was obtained in high yield; however, oligomerization of the HXT was observed by matrix‐assisted laser absorption ionization time‐of‐flight mass spectrometry (MALDI‐TOF MS). Oligomerization was eliminated by running the reaction with only 1.2 molar equivalents of HXT to PSLi and allowing the reaction to run for 15 min at ?10 °C in toluene. The resulting polymer exhibited high diene chain‐end functionality and no oligomerization was observed by MALDI‐TOF MS. ¹³C NMR spectroscopy and the attached‐proton test (APT), along with calculated chemical shifts, showed the presence of both the 1,2‐ and 1,4‐addition chain‐end structures. Further analysis by the reaction of the functional polymer with maleic anhydride indicated that 18 wt.‐% of the product was unreactive, either because of a 1,4‐addition chain‐end structure or a nonfunctional polymer. The structure of the maleic anhydride‐modified polymer was determined by MALDI‐TOF MS and ¹³C NMR spectroscopy. Preliminary work on the reactivity of the diene‐functionalized macromonomers was performed by the addition of a large excess of PSLi to a solution of macromonomer followed by characterization by size‐exclusion chromatography (SEC).

The formation of hexa‐1,3,5‐triene‐functionalized polystyrenes and their reaction with maleic anhydride.     

Effect of a Water‐Soluble Polymer on Polymer Interdiffusion in P(MMA‐co‐BA) Latex Films

We describe non‐radiative energy‐transfer experiments to measure the rates of polymer interdiffusion in P(MMA‐co‐BA) latex films formed in the presence of poly(vinyl alcohol) (PVOH). PVOH had relatively little effect on the initial efficiency of energy transfer, even when the amount of PVOH was large enough to form the continuous phase. Since Φ_ET(0) is a measure of the interfacial area between D‐ and A‐labeled cells in the film, we conclude that under these circumstances the dispersed P(MMA‐co‐BA) copolymer is in the form of clusters with many contacts between particles containing D and A labels. These large amounts of PVOH also reduce the amount of polymer diffusion that takes place when the films are annealed. When smaller amounts of PVOH are present, the effects are measurable but much smaller. In the presence of 2 to 17 wt.‐% PVOH, the polymer diffusion rate is retarded. The magnitude of the effect increases with the amount of PVOH present, and the effect is larger at 45 °C than at 63 °C. We show that the PVOH has its largest influence at the very early stages of polymer diffusion.

Schematic representation of an energy transfer experiment, which monitors polymer interdiffusion in a latex film.     

Methimazole protects from experimental autoimmune uveitis (EAU) by inhibiting antigen presenting cell function and reducing antigen priming

Methimazole (methyl-mercapto-imidazole, MMI), a compound used clinically in therapy of Graves' thyroiditis, was found to inhibit development of several autoimmune diseases in animal models. It was suggested on the basis of in vitro data that inhibition is through down-regulation of interferon-gamma (IFN-gamma)-induced expression of major histocompatibility complex class I and class II molecules. Here, we investigate the effect of MMI on experimental autoimmune uveoretinitis (EAU) and study its mechanism(s). Treatment of EAU with MMI administered in drinking water inhibited induction of the disease and associated antigen (Ag)-specific proliferation and cytokine production by draining lymph node cells (LNCs). The treatment was protective only if administered during the first but not during the second week after immunization, suggesting an effect on the induction phase of EAU. It is interesting that MMI inhibited disease in IFN-gamma knockout mice, indicating that the in vivo protective effect is IFN-gamma-independent. Flow cytometric analysis of draining LNCs extracted 5 days after immunization showed that MMI partly to completely reversed the increase in Mac-1(+)/class I(+)/class II(+) cells induced by immunization and reduced the proportion of B7-1 and CD40-positive cells, suggesting a deficit in the Ag-presenting cell (APC) population. APC from untreated mice largely restored antigen-specific proliferation of MMI-treated LNCs. We suggest that MMI inhibits EAU at least in part by preventing the recruitment and/or maturation of APC, resulting in reduced generation of Ag-specific T cells.     

Linear Nevus Sebaceus Syndrome with bilateral complex limbal choristomas and extraocular muscle involvement

A case of a child with bilateral fleshy limbal masses with a coloboma of the right upper lid is discussed. Systemic examination revealed two patches of alopecia on the right frontoparietal and right occipital areas of the scalp. Punch biopsy and histopathological examination led to the diagnosis of Linear Nevus Sebaceus Syndrome (LNSS) with bilateral complex limbal choristomas. The authors have stated that they do not have a significant financial interest or other relatioship with any product manufacturer or provider of services discussed in this article. The authors also do not discuss the use of off-label products, which includes unlabeled, unapproved, or investigative products or devices.