Not all that blows up is bipolar (but some of it is!) Evidence-based assessment and treatment for bipolar disorders in youths and young adults Eric Youngstrom, Ph.D. UNC Chapel Hill USA Disclosures NIH R01 MH066647 (PI: E. Youngstrom) NIH R01 MH073967 (PI: R.L. Findling) E. Youngstrom has consulted with Pearson, Lundbeck, Otsuka, Janssen, Western Psychological Services about assessment Chief Scientific Officer for Joe Startup Technologies, LLC No speakers bureaus, pharma supported talks, stock ownership, test sales…. Objectives Learn base rates in different settings, such as public Shortcuts to work faster! schools, outpatient services, forensic settings, and inpatient units; and how to use these benchmarks to evaluate efficiently Be more accurate! Use assessment procedures to aid in differential diagnosis and measuring response to treatment Apply new methods for interpreting test results, Get better results! including methods taking into account clinical settings where we work Nebraska Psychological Association Eric Youngstrom, Ph.D. June 8, 2018 University of North Carolina at Chapel Hill Davie Hall, Chapel Hill, NC 27599-3270 eay@unc.edu
Handout Handout What do you think is going on? Diagnosis? What’s your assessment plan? Treatment options? Nebraska Psychological Association Eric Youngstrom, Ph.D. June 8, 2018 University of North Carolina at Chapel Hill Davie Hall, Chapel Hill, NC 27599-3270 eay@unc.edu
Teasers One will have “classic” bipolar I One won’t have any mood disorder (and we won’t discuss a lot further) One will die over the course of the history we know Lea Stressed out senior? 18 yo WF Middle of senior year Coming to outpatient clinic Presenting problem: Trouble with attention Can’t stay focused Grades dropping Getting anxious and stressed about graduating (and if she’ll graduate) Christopher Going off the rails? 14 year old white male Smart, skipped grade, popular Changed clothes, music Started “hooking up” with older brother’s female friends Now tired, missing school for weeks at a time What’s you diagnostic hypothesis at this point? Nebraska Psychological Association Eric Youngstrom, Ph.D. June 8, 2018 University of North Carolina at Chapel Hill Davie Hall, Chapel Hill, NC 27599-3270 eay@unc.edu
DeShawn The Boy Who Blows Up 7 year old black male referred because of extreme aggression and distractibility, motor agitation at school Dad has been diagnosed with Bipolar I and treated for several years with lithium and divalproex. What’s you diagnostic hypothesis at this point? Chances of bipolar? Tamika From Grouchy to Kaboom! 11 y.o. black female, regular ed. Increased anger, aggression, being “hyper,” having trouble sleeping, lying, talking to herself, and stealing. Tantrums: screamed, threw things, broke a plate and some toys… mom worried she might hurt someone. Now lower grades and disruptive in class - talking out, easily distracted, arguing with peers & teachers. Overwhelming amounts of new data Medical information now doubles every 5 years Cochrane estimates that <20% of clinical decisions evidence based IBM estimates that <20% of information guiding decisions is evidence based <2% of published data are 81% of physicians report both reliable and would <=5 hours per month change clinical care reading journals Nebraska Psychological Association Eric Youngstrom, Ph.D. June 8, 2018 University of North Carolina at Chapel Hill Davie Hall, Chapel Hill, NC 27599-3270 eay@unc.edu
Leaky Pipeline Aware Accept Target Doable Recall Agree Done Valid Research If 80% achieved at each stage then .8 x .8 x .8 x .8 x .8 x .8 x .8 = 21% delivered! Early 1990s Where were you? (Working on master’s thesis) First modern “sightings” of pediatric bipolar Geller 1993 Depression Trial Wozniak 1995 JAACAP paper (ADHD sample) 1999 Papolos book Pediatric Bipolar: More than 10,000 articles (590 in 2014 alone) Nebraska Psychological Association Eric Youngstrom, Ph.D. June 8, 2018 University of North Carolina at Chapel Hill Davie Hall, Chapel Hill, NC 27599-3270 eay@unc.edu
The Evidence Base May 2018 Count of PubMed Indexed Citations Pediatric Bipolar 600 10,361 hits 500 400 PBD 300 DMDD/SMD Poly. (PBD) 200 100 SMD/DMDD 147 hits 0 1950 1970 1990 2010 500+ new articles each year: textbooks are out of date as soon as they are published Comparing the Evidence Base October 2013 (~DSM-5) MeSH Filter Pediatric Bipolar SMD/DMDD Total Citations 7606 56 “Clinical Trial” 729 7 Free Full Text 784 3 Review 811 4 Meta-analysis 48 0 Nebraska Psychological Association Eric Youngstrom, Ph.D. June 8, 2018 University of North Carolina at Chapel Hill Davie Hall, Chapel Hill, NC 27599-3270 eay@unc.edu
Revolutionary changes in knowledge of bipolar What we are learning: What we used to think: Rare (~1% of adults) More common (~4% of adults R-Rated (onset after 18) More than 50% have mood onset in childhood & Severe adolescence Treatment is medication Spectrum of presentations Incurable Full range of treatments Survivable and “thrivable” Conventional Wisdom Adult disorder, with median age of onset around 18-20 years Distinct mood episodes Good functioning before illness and between episodes “Touched with Fire” – creativity and productivity during hypomania The Gift Many famous artists, musicians, and politicians are likely to have had bipolar disorder Composers: Handel, Schumann, Schubert; Charlie Mingus, Charlie Parker, Bud Powell… Artists: Jackson Pollak… Poets: Sylvia Plath, Anne Sexton, Dylan Thomas… Nebraska Psychological Association Eric Youngstrom, Ph.D. June 8, 2018 University of North Carolina at Chapel Hill Davie Hall, Chapel Hill, NC 27599-3270 eay@unc.edu
The cost: 7 th leading cause of disability in the world, ahead of all other mental illnesses except depression (Murray & Lopez, 1996; Lopez et al., 2006) Increased substance abuse Increased incarceration One of the leading causes of suicide 18% of adults with bipolar end own life Changes in Rate of Mood, Schizophrenia Diagnoses DSM-II DSM-III DSM-III-R Stoll, A., Tohen, M., et al. (1993) AJP Increase in diagnosis of BD in youth DSM-III-R DSM-IV (adds II, NOS) DSM-5 ????? 40-fold increase in rate of dx Moreno et al., 2007 Nebraska Psychological Association Eric Youngstrom, Ph.D. June 8, 2018 University of North Carolina at Chapel Hill Davie Hall, Chapel Hill, NC 27599-3270 eay@unc.edu
Risk factors may vary by region: DRD4 Gene 32% 1% 42% 78% Genetic “Iceberg” Recognized (Bipolar I, II) Spectrum (missed bipolar I & II; Cyclothymia, NOS) Unimpaired (low loading, high functioning family members, “hyperthymic”) Challenges to “Adults Only” Rating Age of onset appears to be earlier than previously thought (median of 18 means 50% were 18 or younger) Some data suggest progressively earlier age of onset since WW II (genetic anticipation?) Epidemiological studies appear to be underestimating prevalence in adults, especially for “softer spectrum” bipolar Nebraska Psychological Association Eric Youngstrom, Ph.D. June 8, 2018 University of North Carolina at Chapel Hill Davie Hall, Chapel Hill, NC 27599-3270 eay@unc.edu
Obesity and bipolar disorder Obesity associated with bipolar independent of medication effects Inflammatory response Obesity driving down age of puberty 20% of 8 year old girls in USA Hormonal changes associated with mood now happening out of step with brain development Other reasons for changes in rate of bipolar Better assessment Greater awareness …but could be expansion of category Diagnostic stretch (“use drug before it stops working”) Disease mongering Meta-Analysis of Child Epidemiological Studies How common is the bipolar spectrum in youths around the world? Is the rate increasing in the community over the same time frame that clinical diagnosis has changed? Is it more common in the USA than the rest of the world? Van Meter, Moreira, & Youngstrom (2011) J Clin Psychiatry Nebraska Psychological Association Eric Youngstrom, Ph.D. June 8, 2018 University of North Carolina at Chapel Hill Davie Hall, Chapel Hill, NC 27599-3270 eay@unc.edu
No increase in rate of bipolar in community samples Prevalence of Bipolar Spectrum No difference USA rate vs. World Non-USA USA Van Meter, Moreira, & Youngstrom, 2011, J Clin Psychiatry USA not driving increase of PBD 1.2% 2.8% 0% 1.9% 2.4% 2.5% 1.8% DSM Bipolar I is most heavily researched, greatest validity Only if elated or grandiose “Narrow” BP-I (DSM-IV) “Intermediate” BP-II Severe Cyclothymia??? Mood “Broad” Dysreg. Bipolar NOS (SMD) Youngstrom (2009) CP:SP Nebraska Psychological Association Eric Youngstrom, Ph.D. June 8, 2018 University of North Carolina at Chapel Hill Davie Hall, Chapel Hill, NC 27599-3270 eay@unc.edu
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