Children of Parents with Bipolar Disorder in the United States are at High Risk for Depression, Anxiety, and Multiple other Disorders: Implications for Research, Monitoring, Treatment, and Prevention

Special Article - Depression among Children and Adolescents

Ann Depress Anxiety. 2015; 2(7): 1071.

Children of Parents with Bipolar Disorder in the United States are at High Risk for Depression, Anxiety, and Multiple other Disorders: Implications for Research, Monitoring, Treatment, and Prevention

Robert M Post*

Department of Psychiatry, George Washington University School of Medicine, USA

*Corresponding author: Robert M Post, Department of Psychiatry, George Washington University School of Medicine, Bipolar Collaborative Network, 5415 W. Cedar Lane, Suite 201-B, Bethesda, 20814, USA

Received: November 12, 2015; Accepted: December 22, 2015; Published: December 23, 2015

Abstract

In the United States (US) some two thirds of bipolar disorder in adults begins in childhood and adolescence compared to one third in Europeans. Two major risk factors for early onset include genetic/ familial loading and psychosocial adversity in childhood. There is a higher incidence of both of these factors in the US than in many other European countries. The parents, grandparents, and offspring of the US patients also have a higher incidence of illness than the Europeans, including more depression, bipolar disorder, alcohol and substance abuse, and “other” illness. Parents with mood disorders convey increased risk of mood and other childhood psychiatric disorders to their offspring via both genetic and epigenetic mechanisms. The incidence and earlier onset of these illnesses in childhood also appears to be increasing in the general population based on a cohort effect. Early onset bipolar disorder and depression have a more difficult course and prognosis than adult onset illness, in part related to a longer duration of the lag from illness onset to first treatment; yet this is a remedial risk factor. Increased vigilance for early onset mood and behavioral disorders based on the known clinical risk factors and more systematic monitoring of symptom emergence and response to treatment may help with earlier psychotherapeutic and pharmacotherapy interventions and help ameliorate the long term adverse consequences of childhood onset mood disorders. New research, clinical treatment, and public health initiatives are desperately needed.

Introduction

Two of the most powerful risk factors for childhood onset bipolar disorder and depression are a positive family history of these mood disorders and the occurrence of psychosocial adversity in childhood. To these well-known factors, we would suggest that being from the United States (as opposed to many European countries) is an additional risk factor interacting with the two above [1].

Multiple other risk factors are known, such that clinical history alone, without waiting for further genetic and neurobiological risk factors to be discovered and replicated, are already enough to encourage increased vigilance for childhood onset depressive, anxiety, and behavioral disorders. If, in addition to genetic and psychosocial risk factors, there is already the presence of prodromal symptoms, then careful monitoring is indicated, and psychosocial and pharmacological treatment should be considered as necessary [2,3]. In this brief commentary and overview, we highlight the need for greater awareness of childhood onset mood and behavior disorders with an emphasis that the incidence of both the vulnerability factors themselves and childhood onset bipolar disorder are greater in the US than many non-US countries. As such changes in the usual, typically delayed assessment and treatment paradigms in the US are warranted.

Vulnerability Factors for Childhood Onset Mood Disorders

Bipolar disorder or depression in parent

Bipolar disorder in a parent conveys a very high risk of depression and anxiety in the offspring, as well as a wide range of other childhood psychiatric diagnoses. Axelson et al. [4] found that the following disorders occurred more often in offspring of a bipolar parent compared to offspring of community controls; this included an anxiety disorder (39.9% vs. 21.8%); depression (32.0% vs. 14.9%); ADHD 30.7% vs. 18.2%); disruptive behavioral disorder (27.4% vs. 15.3%); bipolar spectrum disorder 22.5% vs. 2.0%); and substance abuse 20.0% vs. 10.1%). Strikingly, 74% of the offspring of a bipolar parent had a major psychiatric diagnosis upon 6.7 years of follow up. Also startling was that in the matched community controls (parents without a diagnosis of bipolar disorder), about 50% of the offspring had a major childhood psychiatric diagnosis [4] indicating a very high prevalence of childhood onset disorders in the general population of the US. Similar findings of high risk for depression and many other psychiatric illnesses in the offspring of parents with serious psychiatric illness are seen in meta-analyses [5]. Axelson et al. [4] found that in offspring of a parent with bipolar disorder, the presence of depression, Bipolar-Not Otherwise Specified (BP-NOS), or Disruptive Behavioral Disorder (DBD) predicted the conversion to full BP I or II disorder upon follow up, and suggested that early intervention in the treatment of these disorders could help prevent the conversion to bipolar disorder.

A family history of parental depression is also well-known risk factor for depression in the offspring. The long term follow up data of Weissman et al. [6] are particularly revealing. Upon 20 years of follow up, 82% of the offspring of a parent with unipolar depression had a major psychiatric diagnosis, with depression and an anxiety disorder being particularly prominent. If both parents are ill, the risks to the offspring are even greater [7,8]. Moreover, multi-generational influences are also apparent. Weissman et al. [9] found that a grandparental history of depression conveyed an additional risk for depression in the offspring, and the effect of grandparental illness alone was even greater than the effect of parental depression alone.

Other work has revealed that the degree of wellness of the parent with depression is important to the well being of the offspring.

Wickramanratne et al. [10] found that treating a mother’s depression to full remission, as opposed to treating without achieving remission, resulted in less psychiatric illness in the offspring. A history of a suicide attempt in a parent is likewise a very high risk factor for a suicide attempt in the offspring [11].

US versus European illness vulnerability

In our Bipolar Collaborative Network we had 4 sites in the US (Los Angeles, Dallas, Cincinnati, and Bethesda) and 3 in the Netherlands (Utrecht) and Germany (Freiberg and Munich), here referred to as “Europe”. The patients with bipolar disorder from the US were more ill than those from Europe. This included more: early onset illness, anxiety disorder comorbidity, substance abuse, rapid cycling, > 20 prior episodes, and more treatment refractoriness on prospective naturalistic follow up. Bellivier et al. [12] have replicated our observations of more childhood onset bipolar disorder in the US than in Europe, comparing data from the Pittsburg bipolar disorder case registry to that of 10 different European countries. Similarly, Etain et al. [13] found earlier onset bipolar disorder in the US than in France.

In our Network, the offspring of parents with bipolar disorder from the US had more depression, bipolar disorder, substance problems, and “other” illness compared to those from Europe [14] (post et al. 2015, JAD). This burden of illness was related to the overall burden of psychiatric illness in the offspring’s parents (our Network patients) as well as the child’s grandparents and great grandparents [15,16]. This illness burden in both grandparents and greatgrandparents was greater in those from the US compared to Europe for depression, bipolar disorder, drug abuse, and “other” illness, indicating 4 generations of greater illness burden in those from the US compared to Europe (Table 1).

Citation:Post RM. Children of Parents with Bipolar Disorder in the United States are at High Risk for Depression, Anxiety, and Multiple other Disorders: Implications for Research, Monitoring, Treatment, and Prevention. Ann Depress Anxiety. 2015; 2(7): 1071. ISSN : 2381-8883