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NIMH Expert Dr. Mary Rooney Discusses Bipolar Disorder in Adolescents and Young Adults

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MARY ROONEY: Thank you for joining me today. I'm Dr. Mary Rooney, a clinical psychologist and chief of the Child and Adolescent Psychosocial Interventions Research Program at the National Institute of Mental Health or NIMH, which is part of NIH, the National Institute of Health. For world bipolar day, we're focusing on adolescents and young adults for the discussion. And while bipolar disorder is far less common than depression in adolescents, it can be extremely impairing and is associated with a high risk for suicide if it's left untreated. Bipolar disorder can be particularly difficult to diagnose in adolescents if they're already experiencing mood swings related to activity and hormonal changes, and the signs and symptoms of bipolar disorder may overlap the symptoms of other disorders that are common in young people like ADHD, conduct problems, major depression, and anxiety disorders. So diagnosing bipolar disorder can be complicated and it requires a careful and thorough evaluation by a trained and experienced mental health professional. During the next half hour, I'll provide an overview of the signs and symptoms, proper diagnosis, and treatments for bipolar disorder in adolescents and adults. I'll also discuss some of the challenges that the COVID-19 outbreak has presented for individuals living with bipolar disorder. And if there's still time at the end, I'll also take some of your questions, so please, ask them in the comments section under this video feed on Facebook or tweet NIMH on Twitter.

It's important to note that I can't provide specific medical advice or referrals, so please consult with a qualified healthcare provider for diagnosis, treatment, and answers to your personal questions. And if you need help finding a provider, please visit www.nimh.nih.gov/findhelp. And if you or someone you know is in crisis, please call the National Suicide Prevention Lifeline at 1-800-237-TALK. You can also ask for help in the comments section of this feed, and someone from NIMH will assist. All of the websites and phone numbers that I just mentioned will also be posted in the comments section of this feed so that you can easily access them. So let's start by talking a little bit about what is bipolar disorder and what are some of the signs and symptoms. So bipolar disorder is a mental disorder that causes people to experience noticeable, sometimes extreme, changes in mood and behavior. And sometimes children with bipolar disorder feel very happy or up and are much more energetic and active than usual, and this called a manic episode, and sometimes children or teens and young adults with bipolar disorder feel very sad or down and are much less active than usual. So this called a depressive episode. Bipolar disorder, which used to be called manic depressive illness or manic depression is not the same as the normal ups and downs that every other young adult or teen experiences.

The mood changes in bipolar disorder are much more extreme, they are often unprovoked and accompanied by changes in sleep, energy level, and the inability to think clearly. Bipolar symptoms can make it hard for young people to perform well in school or get along with their friends and their family members. Mood episodes in bipolar disorder include intense emotions along with significant changes in sleep habits, activity levels, thoughts, or behaviors, and a person with bipolar disorder may have manic episodes, depressive episodes, or mixed episodes, which includes both manic and depressive symptoms. These mood episodes cause symptoms that often last for several weeks or days, and during an episode, the symptoms last every day for most of the day. And as I mentioned before, these mood and activity changes are very different from a person's usual behavior and from the behavior of healthy people the same age. So children and teens having a manic episode, they might show intense happiness or silliness for long periods of time. They have a very short temper or seem extremely irritable. You'll find that they talk fast about a lot of different things and think from topic to topic quickly. They'll have trouble sleeping, but they won't feel tired the next day. And they'll have trouble staying focused and experience racing thoughts, where the thoughts are going through their head faster than they can even keep up with.

They'll seem overly interested or involved in pleasurable but risky activities, and they'll very likely do riskier reckless things that show what most people would consider to be poor judgment. Children, teens, and young adults who are having a depressive episode might feel frequent and unprovoked sadness, show increased irritability, anger, or hostility. They complain a lot about pain like stomach aches, headaches. In contrast to a manic episode, you'll notice that someone in a depressive episode will have a noticeable increase in the amount of sleep. So they'll be sleeping a lot more than usual. They'll also have difficulty concentrating. They may feel hopeless or worthless, will have difficulty communicating or maintaining friendships. They'll eat more. Either too much or they'll eat too little. And they'll have little energy and they'll have almost no interest in activities that they usually enjoy. And they also think about death and have thoughts of suicide or wanting to hurt themselves. So who can develop bipolar disorder? Well, technically, anyone can develop bipolar disorder. And most people with bipolar disorder develop it in their late teens or early adult years, and occasionally, bipolar disorder symptoms can appear in children. We don't know what cause bipolar disorder, but we do know that it can run in families. And this doesn't mean that just because someone in your family has bipolar disorder it just means that you or someone else in your family will develop it, it just means that your chances of developing it are a bit higher because someone in your family has it already.

Another factor that may lead to bipolar disorder is the brain structure or brain function of the person with the disorder. And scientists are finding out more about this disorder by studying it. And if you consider joining an NIMH research study on bipolar disorder to help scientists learn more about it and if you want to learn more about studies that are funded through NIMH, you can go to www.nimh.nih.gov/joinastudy. And if you think you or your child may have bipolar disorder, a professional healthcare provider will carefully examine you or your child and ask about your family's medical history. There's no blood tests or brains scans that can diagnose bipolar disorder, but a provider may use tests to see if something other than bipolar disorder is causing your child's symptoms. Now, let's talk a little bit about how it's diagnosed and what that process looks like. As I mentioned earlier, most people are diagnosed with bipolar disorder in late adolescence or adulthood, but the symptoms can appear earlier. Bipolar disorder is often episodic, right? So there's discreet periods of mania or depression, but the disorder itself is chronic and it typically lasts a lifetime. The healthcare provider will ask questions about your child's mood, speaking patterns, energy levels, and behavior. And while there's no blood tests as I mentioned or brain scans that can be used, the provider may use tests to make sure there isn't something else like a medical condition that might be causing your child's symptoms and use tests like this in those phases.

Sometimes healthcare providers and you need to know about medical conditions in the family like depression or substance use or other mental health conditions. Other disorders also have symptoms that are like those of bipolar disorder, and this can include ADHD, disruptive mood dysregulation disorder, oppositional defiant disorder, conduct disorder, and anxiety disorders. So one of the clinician's main jobs is to distinguish bipolar disorder from the depression that occurs without mania and is often referred to as major depression. The healthcare provider who specializes in working with children, teens, or young adults can make a careful and complete evaluation of your child's symptoms and provide the right diagnosis. Now, when we're thinking about treatments, children, teens, and young adults can work with their healthcare provider to develop a treatment plan that will help them manage the symptoms and improve their quality of life.

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Okay. I think I'm back. All right. Let's start again [inaudible]. Okay. I think I had seemed to be back for [inaudible]. All right. So let's start by talking about medication as a treatment option. So there's several types of medication that can help treat symptoms of bipolar disorder. Children, teens, and young adults respond to medications in different ways, so the right type of medication depends on the individual. So this often means that someone may need to try different types of medication to see which one works best for them before they finally get on one that they are able to take long-term. Some children, teens, and young adults may need to take more than one type of medication because their symptoms are complex. Individuals should take the fewest number of medications in the smallest doses possible to help their symptoms because that way you minimize side effects. So a good way to remember this is as start low and go slow. Always tell your child's healthcare provider about any problems with side effect and have conversations upfront about what the side effects might be so you know what to look out for.

But if you do notice side effects, don't stop giving your child the medication without speaking to the healthcare provider first. Stopping medication suddenly can be dangerous, and it can exacerbate bipolar disorder symptoms. Now, medication isn't the only option, although it's a very important component of treatment for most people with bipolar disorder. Psychosocial therapy or talk therapy [inaudible] also very powerful for bipolar disorder. So different kinds of psychosocial therapy can help children, teens, young adults, and their families manage the symptoms. Therapies that are based on scientific research or what we would call evidence-based treatments include cognitive-behavioral approaches and family-focused therapy. And these treatments provide support, education, and guidance to teens, young adults, and their families. And in each of these treatments, family involvement is a very important component. These therapies teach skills that can help people manage bipolar disorder, including skills for maintaining routines, enhancing emotional regulations, and improving social interactions. Improving family communication and family functioning can also be an important part of these treatments. With treatment, children and teens and young adults with bipolar disorder can get better over time. Treatment is most effective when healthcare providers, parents, and young people all work together as part of a team.

Sometimes a person with bipolar disorder may see their symptoms change or disappear and then come back, and when this happens, your child's healthcare provider may recommend changes to the treatment plan. And treatment can take time, it does require patience, but sticking with the treatment plan can help young people manage their symptoms and reduce the likelihood of future episodes. Your child's healthcare provider may recommend keeping a daily life chart or mood chart, either kept by the adolescent or an adult or kept by parents and the teen or young adult themselves, and this will track your child's moods, behaviors, and sleep patterns. This might make it easier to track the illness and see whether the treatment's working. And if you're not sure where to get help, your doctor, pediatrician, or other family healthcare provider is a great place to start. A healthcare provider probably won't provide the diagnosis and primary care, but they can refer you to a qualified mental health professional like a psychiatrist or a psychologist who has experience treating bipolar disorder and can evaluate your child's symptoms. And you can also start, as I mentioned before, by visiting www.nimh.nih.gov/findhelp. Now, let's talk a little bit about what parents can do to help your teen or young adult.

Help begins with the right diagnosis and treatment. So talk to your family healthcare provider about symptoms you notice as soon as possible. Ad if you find that your child does have bipolar disorder, here are some basic things you can do. You can start by being patient. Mental illness always takes a while to treat, it's not a-- nothing's a quick fix, but when you're patient, it can be effective over time. Keep the lines of communication open with your child, encourage them to talk to you, and listen to your child carefully. Pay attention to their moods and be alert and sensitive to any major changes. If you notice a change, then very quickly reach out to your child's healthcare provider. Learn to understand triggers. Often changes in mood, whether it's a depressive episode or a manic episode, can have triggers that proceed it. And when you are aware of those triggers, you can manage them in advance and even help your child or teen learn strategies for managing intense emotions and irritability, and also focus on managing your own emotions and your irritability. For some teens and young adults with bipolar disorder, family stress and strain can be a trigger, so managing your own intense emotions and irritability can also be an important part of treatment. Helping your child have fun is also very important. It can be easy to lose sight of that when you're in the midst of trying to treat someone with a mental illness, but staving off depressive symptoms and even manic episodes can really be helped by making sure your child is engaging in things that they enjoy doing, and that includes things they enjoy doing with their family.

And remember that treatment takes time, so sticking with a treatment plan can help your child get better and stay better, and help your child understand that treatment may make life better and that if they stick with their treatment plan, they can manage their symptoms. Now, let's just take a minute to talk about the pandemic and its impact on individuals with bipolar disorder and a few things that you can do to manage bipolar disorder within the context of the pandemic. So feelings of anxiety and uncertainty are completely normal during a global pandemic. I think it's something that just about everyone has experienced in the last year, but it can be a lot more challenging facing this uncertainty when you're having a mental illness like bipolar disorder. So it's very important that your child, if they've been diagnosed with bipolar disorder, continue their treatment regimen and to not deviate from that regimen. And if you haven't already, consider developing a plan for telehealth sessions with your doctor so treatment isn't interrupted. And reach out as a parent to friends and family for support and encourage your child to stay connected with other teens or young adults and their friends and their families throughout the remainder of the pandemic and connect virtually if necessary. What we do know is that social isolation increases stress and loneliness and that both of these can be triggers for a bipolar episode.

Now, some people may be more prone to manic episodes where they feel excited or irritable or energized, and while others experience more depressive episodes where they feel more down. So they may have more mild episodes called hypomanic episodes or, as I mentioned before, mixed episodes that involve both manic and depressive symptoms. Each of these kinds of episodes can have their own specific triggers, so it's best as I mentioned before, to map out what these might be in the context of typical life but also being aware of what they might be in the context of the pandemic. It's also important for teens and adolescents-- sorry, teens and young adults to void drugs and alcohol because it can interfere with medications that are used to treat bipolar disorder. And high levels of caffeine can also trigger an episode. Regular exercise like jogging, racewalking, or cycling helps with depression and anxiety, and promotes better sleep and can help stave off manic or depressive episodes. And also some evidence that anaerobic exercise like weight-lifting, yoga, and palates can be helpful, but always check with your child's healthcare provider before they start a new exercise regimen. And even with proper treatment, mood changes can occur. And as I mentioned before, it's most effective when the patient and healthcare provider work together and talk openly about concerns and choices.

So throughout the pandemic, make sure that you continue to maintain an open line of communication with your child's provider and reach out as soon as possible if you notice change in symptoms. Patients can easily also share data now collected via smartphone app. So things like self-reports, ratings, and activity data. And that can be a great way for healthcare providers and therapists to monitor teens and changes in these - in sleep or activity - that might act as a trigger for a bipolar episode or the onset of a bipolar episode. And lastly, it's very important to maintain good sleep hygiene. So loss of sleep is a big trigger and is one of the signs of mania. It's very important to contact your child's doctor if you find that they're not sleeping, and it's a good idea to have a plan in place already to help manage your adolescent or young adult's sleep. And the risk of developing a manic episode, even one night of missed sleep is high. And the consequences of a manic episode might be even greater during these stressful times, so intervening early is key. To hear more information about COVID-19 and strategies for coping, you can visit www.nimh.nih.gov/covid-19. So I want to make sure that we have enough time for some questions from the audience, so I'll stop there, and I'll take a look at some of the questions that are coming.

So one question that I see here is whether ADHD can be misdiagnosed in youth, and it's a case that it's not ADHD, it's actually bipolar disorder. So in youth, especially children and younger teens, it can be very difficult even for a highly trained clinician to distinguish between things like ADHD or a disruptive dysregulation mood disorder and what is earlier symptoms of bipolar disorder. So it does happen that someone who is diagnosed with bipolar disorder later in life, either in late adolescence or in young adulthood, has a history of an ADHD diagnosis. So when a clinician is assessing bipolar symptoms in an adolescent or young adult, they will also be asking about symptoms from childhood. And when a clinician hears that there was a prior diagnosis of ADHD, it's not assumed that what we're seeing now in adolescence or young adulthood is ADHD. We assume that it might still be ADHD or it might be that earlier symptoms that were thought to be ADHD were actually earlier onset bipolar symptoms and now we're seeing what we would consider the full clinical disorder or clinical presentation in adolescence or young adulthood. So yes, that does happen. It's hard to know if it was a clear misdiagnosis in some cases because of the overlap, but yes, a history in ADHD isn't uncommon when someone receives diagnosis of bipolar disorder later.

I see another question here about if there's an age in which children may begin experiencing bipolar disorder symptoms. So there's a lot of variability, but when you see the onset of really discreet manic or depressive episodes, usually, it's in mid to late adolescence is the earlier time when you see it. Now, there are some cases where we do see it earlier, but the younger you go, the rarer it is. So what we think of as classic bipolar disorder episodes, usually, we don't see until mid to late adolescence at the earliest. However, there may have been some symptoms that were emerging earlier and that's where some of the diagnostic confusion comes in, when you get into younger age ranges. A question here about what type of assessments doctors use to diagnose. So most clinicians will use a combination of what we call semi-structured clinical interviews. So these are interviews where there's question prompts about various symptoms, not just of bipolar disorder, but also other disorders like ADHD or depression or anxiety disorders or even PTSD. And all of those disorders are assessed because we want to rule out anything other than bipolar disorder, right, if we're trying to focus on whether it's bipolar disorder or not.

And in those questions, we're trying to assess how often do these symptoms happen and how intense ae they. Right? Do they rise to the level of being something that's clinical? Or are they something where it's kind of typical for an adolescent who might be going through some hormonal changes and having some mood swings? Does it fall within that range of typical or is it really something that we're seeing that rises to the level of a clinical problem within that symptom? So in addition to those semi-structured interviews, which often happened with parents as well as with the adolescent themselves-- and so we assessed both because parents provide a different perspective than the adolescent of course, and have a good handle usually on the adolescent's history. But the adolescent can provide a wider insight into their current mood state, level of anxiety, etc. And in addition to those interviews, often we'll also use rating scales, and these rating scales are normed. So they're scales that have been administered to thousands of children at the same age and gender, and what we're looking for in these rating scales that are completed by parents and the adolescent and sometimes also by teachers are, do the responses fall in what we see in kind of a typical response range for all of the thousands of people who have taken this measure already or been in this sort of measure already, or are they falling in an elevated range?

So it's the combination of those rating scale responses and those semi-structured interviews that really give us the information we need to make a diagnosis. And occasionally, also some medical tests will be run to rule out a medical cause of the condition. We have a few other great questions here as well. So someone's asking what should a parent look for when finding a mental health professional for your child? So that's a great question. The main thing that you-- there's a bunch of different things that you want to look for, but some things that can really be a proof that you're onto someone who's really going to be providing some evidence-based treatments is looking for someone who-- looking for what we know are evidence-based treatments for bipolar disorder like cognitive-behavioral therapy or family-focused therapy, and do they have training in that. Is that one of the main modalities of treatment that they provide? Are they someone who provides treatment to adolescents and young adults regularly? And what is their history of treating bipolar disorder? Also, because bipolar disorder also often includes pharmacotherapy or medication as well, it's ideal if they have close relationships with psychiatrists, either because they're part of the same practice or they're someone they work with regularly.

And in the most ideal of situations, you would want to find a provider who's affiliated with an academic medical center or a group practice that is specialized in adolescents or bipolar disorder. Accessing treatment can be tricky if you don't live in a major metropolitan area where a lot of clinicians are found, especially those who are more specialized. Currently, fortunately with telehealth being used more frequently you can look further away from home if you're comfortable with telehealth sessions, but I always recommend that people stay within their home state because things could get tricky with licensure. So you want to find a clinician whose licensed in the state where you live. Let's see. What about trauma and its impact on affect regulation? So that's also a great question. Trauma symptoms can mimic or mirror a lot of other disorders as well. It's not common for kids, adolescents, and young adults to be misdiagnosed with something like ADHD, an anxiety disorder that's not trauma-specific, or even a behavioral disorder like conduct disorder or oppositional defiant disorder, or really any other disorder that does involve affect and mood regulation challenges. So when you have a diagnostic assessment completed, the clinician should also assess for trauma history and take that into consideration, and that's really all part of the diagnostic picture and parsing out whether or not the symptoms that are being seen currently are related to the trauma or if they are not completely unrelated, maybe influenced by the trauma but are really a discreet mental illness.

So that's a number of additional reasons why a very comprehensive diagnostic assessment is so important. And we're getting close to our wrap-up time here, so I'm going to stop answering questions, but thank you to everyone for listening, and thank you for the great questions that were submitted. And, again, my main take-home message today, I think, would be that if you're seeing symptoms in your adolescent or young adult and you have any concerns, please reach out as quickly as possible to your child's primary care provider to get some referrals to a qualified clinician who can conduct an assessment. Thank you, everyone, take care.

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