Late diagnosis of bipolar disorder in children and adults

75% of the cases of paediatric bipolar disorder are diagnosed late - up to 18 months - due to the symptoms manifesting themselves in a different manner depending on whether the patient is a child or adult. Moreover, 25% of sufferers have a delay in their medical diagnoses of up to three years and four months, according to a study by the Department of Psychiatry and Medical Psychology at the University Hospital of Navarra, in collaboration with the Paediatric Psychopharmacology Unit at the l Massachusetts General Hospital at Harvard University (Boston, United States).

As doctor Inmaculada Escamilla Canales, specialist at the Madrid-based Child and Adolescent Psychiatry Unit of the University Hospital of Navarra explained, the research was based on an article previously published by her department in 2005 in which the perspectives of bipolar disorder amongst children outside the USA were reviewed. A very low incidence was observed in Europe compared to the North American samples, especially amongst certain countries. Also, in Great Britain, a study undertaken with a sufficiently representative sample concluded that the rate for this illness was non-existent.

This research was the focus of the PhD thesis of Ms Inmaculada Escamilla, who contrasted and completed the results during her stay in Massachusetts Hospital. It was seen that there was a gap between the United States and Europe as regards the incidence and the diagnosis of bipolar disorder amongst children and adolescents. The research team wanted to find out why this was the case. They came to the conclusion that in Europe the disorder was being infra-diagnosed in most cases. It was being diagnosed late or incorrectly, a situation that has had a negative influence on the response to treatment, Ms Escamilla pointed out.

According to doctor Escamilla, the research is original and tackles a controversial question in Europe, where the illness is known and diagnosed amongst adults, but not amongst children. In fact, studies carried out amongst adults show that 60% had had the beginnings of the disease before the age of 20.

A sample of 38 cases diagnosed in six years

The research was undertaken with a group of 38 boys and girls who had been diagnosed with bipolar disorder at the Child and Adolescent Psychiatry Unit of the University Hospital of Navarra over a period of six years. According to doctor Escamilla, the symptoms manifesting themselves before and during diagnosis were recorded, they analysed family psychiatric histories, any treatment received, school progress, and so on. The aim was to describe the disorder so that the early detection and diagnosis of it could be effected, pointed out doctor Escamilla.

As a consequence, an incidence of the disorder of 4.6% was found, a percentage approaching that of a number of studies from the US with similar clinical samples. The results suggest that bipolar disorder amongst children and adolescents goes beyond the frontiers of the United States, despite the criticism and certain scepticism of a large section of European scientists. The average age at diagnosis was 13.9 years.

Thus, the study showed that only 25% of the patients are diagnosed within the first seven months from the moment the symptoms of the disorder manifest themselves. Another 50% receive a correct evaluation of their condition between 18 months and three years and four months after the onset of the symptoms. This delay is more than three years and four months for the remaining 25%.

According to other results of this research, prior to the definitive medical report, patients were diagnosed with multiple disorders, up to four different ones in 14% of cases. The most frequent of these were: behavioural disorder, lack of attention and hyperactivity and depression. As a consequence, added doctor Escamilla, patients received different treatment: a third of the cases had been treated with three different pharmaceutical drugs. How these course of medication influence the course of the illness is currently being studied, given that in some case they acted as stimulants.

Likewise, the study showed that 92% of patients diagnosed with paediatric bipolar disorder manifested another disorder. 18% had at least three associated psychiatric disorders, a situation that indicates an important comorbility in this illness. The disorders that appear associated with most frequency attention deficit and hyperactivity (21%) and those derived from consumption of substances, which come to 18%.

Irritability the symptom most frequent amongst children and adolescents

Both diagnostic delay and error with paediatric bipolar disorder are related, according to doctor Inmaculada Escamilla, with the distinct presentation of the disorder in children and adults. Amongst children, the most common mood change is irritability, while in adults a typical manifestation is euphoria and expansiveness. In fact, a symptom like euphoria, related to bipolar disorder, appears in at least half of the paediatric patients.

In this vein the specialist points to the fact that the key lies in evaluating the type of irritability, a manifestation that also appears in depression disorders. In paediatric bipolar disorder, the characteristic irritability is explosive and severe. On occasions significant violence happens in short or sporadic outbursts, and often this is not reactive to anything or the trigger is minimum. It can be confused with a tantrum, but is much more disproportionate. Likewise, she added, unlike the progress of the illness amongst adults, the episodes in children are not clearly defined: very frequent changes in mood and these fluctuating rapidly. Rarely does a sufferer have a period of at least two months without symptoms. This form of instability means that the illness is highly disabling.

Also, symptoms such as euphoria and expansiveness appear in child patients, but with less frequency than in adults and with other characteristics: expansiveness in a child may manifest itself at school, where it is deemed by the patient that he or she has more authority than the teacher, who is thus defied, and is then interpreted as a behaviour problem. Also observed is social non-inhibition amongst these children. For example, making derogatory or rude comments in a loud voice about other persons in public or even of sexual content inappropriate for his or her age, remarked the specialist.