To continue to do our part in bringing awareness to Bipolar Disorder Awareness Day today we sat down with Dr. Benjamin Goldstein to ask him some of the most common questions we hear from parents about Bipolar Disorder. Dr. Goldstein is the Director for the Centre of Youth Bipolar Disorder at CAMH (based in Toronto) making him our first ever international interview! To stay up to date with Dr. Goldstein's work follow him on twitter @bengoldstein73.
1. Can you tell us a little bit about yourself and the work you’re doing?
“I'm a child and adolescent psychiatrist and all of my career efforts focus on teenagers with bipolar disorder or those at familial risk for bipolar disorder. I am a clinician-scientist so I integrate research into my clinical care with the goal of generating discoveries that are relevant to patients and families. In particular, I focus on the link between bipolar disorder and heart disease for the purpose of identifying novel ways to improve symptoms and functioning.”
2. What are some tangible signs that a parent could notice in their child that could prompt them to seek professional mental health services for bipolar disorder?
“I think the determination of whether a child has bipolar disorder is a little more complicated, I think the more straightforward question is ‘Is there something wrong with the child on an emotional or behavioral level?’ Because there's a lot of common things that cause difficulty in young people in relation to their feelings, thoughts, and behavior, and once someone has determined that there's something different about their child they can begin to look at specific aspects together with a mental health professional.
In terms of mental health problems in general, things we’re concerned about are changes in functioning and things that are atypical for that young person. Someone who is interested in school and now is no longer interested in school or someone who has changes in the quality or nature of their social or family relationships.
In particular, relating to bipolar disorder, if we're talking about the symptoms that are most distinguishing, those are manic symptoms and those are by definition observable to others. The types of things that we see when someone has mania or significant manic symptoms that are relatively unique to bipolar disorder is that they have a profound amount of energy that's uncharacteristic for them, that comes along with a change in their mood towards elation or excess happiness often intermixed with irritability. They behave in ways that are uncharacteristic in terms of being disinhibited or risk-taking. Everything will be sped up in terms of their thoughts, speech, and behaviors. They may have something called inflation if their self-confidence is beyond what is usual for them along with other symptoms.
When you see those symptoms come in a cluster, in a way that's uncharacteristic for the person, that is highly suspicious for a bipolar spectrum disorder and warrants an evaluation. The other comment I would add is that the likelihood of a given set of symptoms being part of a bipolar disorder is influenced by the family history. So, most offspring of parents with bipolar disorder will not have bipolar disorder themselves but they are at a ten-fold increased risk. And the reason that's important is that anxiety and depression are very common among youth offspring of parents with bipolar disorder. Common treatments for anxiety and depression are antidepressants which if there's a genetic risk for bipolar could exacerbate their symptoms, or potentially cause a flip into mania. It's not the case that those treatments aren't allowed, just the case that more caution and more thought should be given before using those medications in those offspring of parents with bipolar disorder.”
3. When people hear about bipolar disorder and don't know much about it, they tend to think of very high, highs and, very low lows. Is this a case for every individual with bipolar disorder?
“It depends in part on the bipolar subtype. But yes, I would say that a persistent high mood in a way that's pathological is one of the defining features of bipolar disorder. There are some people who have mania or milder versions we call hypomania, where the mood is not really elated but rather irritable with high energy. But the overwhelming majority of people with bipolar while manic or hypomanic will have elation and certainly, they'll have elevated energy.
In terms of depression, the vast majority of people with bipolar will have episodes of major depression. There are some people who will have more fleeting episodes of depression or who won't have depression at all. But that is the minority. In fact, in youth, similar to adults, if you look at the burden of symptoms, meaning the proportion of someone's life impacted by mania versus depression, it's depression that really dominates. People spend much more of their lives in depression than in mania. And so, while the most distinguishing feature of diagnosis is mania or hypomania, it’s depression as well as co-occurring conditions like anxiety and attentional problems that are particularly difficult to treat.”
4. As a professional working in this field. Is there one tip you could give a parent who has a child who was recently diagnosed with bipolar disorder to support their child?
“I think the most important thing at the outset when a family is facing a challenge like this is to nurture collaboration. Nurture collaboration amongst family members, between family members and the affected child, between family members and the treatment team. This is a huge stress. Oftentimes treatment is not fully effective or is associated with side effects. That, taken together with uncertainty about the diagnosis, because often people have been given different diagnoses, creates tensions between the treatment team and the family and I think that nurturing collaborations helps youth and helps families focus on working together towards eventually getting well.
The other thing I would suggest is the value of arming oneself with knowledge, and knowledge from high-quality sources. So, not all high-quality sources are medical journals but there are consumer advocacy groups and support groups that are non-medical yet have reliable information publicly available you know, encourage people to go to those for information and to come to appointments with questions.”
5. Can a child outgrow a bipolar disorder diagnosis?
“It's a good question. There is not enough knowledge on this specific topic to give a definitive answer. And the reason it's difficult to give a definitive answer is that even before there was any form of treatment for bipolar disorder over a hundred years ago, it was knowing that people could go a decade or more without the symptoms of bipolar disorder and have it come back. So, people are reluctant to say that they've outgrown it necessarily. Having said that, there are some studies of youth and young adults showing that people who as children or adolescents initially showed evidence of manic or hypomanic episodes can go years without having those episodes in the absence of treatment.
The question is determining who those people are because anybody could take the chance to not engage in treatment but that's a risk and we don't have, at this point, a way of determining who is going to be in long-term recovery or has perhaps grown out of the illness and who remains at risk for reoccurrences.
Some of the work by my colleague and mentor Boris Birmaher and his group has looked at risk calculators to help clinicians and families and patients make more empirically guided estimates of how likely it is that they're going to have more episodes. At this point, it's still in the early going but the hope is that within the next decade that becomes part of clinical care.”
6. You mentioned that bipolar disorder has a genetic element. If a parent has bipolar disorder, should they automatically get their child or children evaluated?
“I wouldn't suggest that they should automatically do that, but I would say that if the parent is very anxious about it then there may be some value to have that assessment. If they're not I think it's completely reasonable to take a wait-and-see approach.
I think if they're seeing signs of changes or problems with their youth, you know, time is of the essence. Early intervention is thought to yield better results. The other thing that's important to know is that whatever is good and healthy for any kid is going to be especially good and healthy for people with risk for mental disorders. By that, I'm referring to regular sleep, activity, exercise, positive social relationships, and avoiding trauma. So, those are all things that anyone would recommend. But the potential benefit to people at risk for bipolar disorder is increased.”
7. What kind of an outcome can a parent/primary caregiver expect once their child receives the diagnosis of bipolar disorder?
“I've been working in this field for fifteen years and I've seen the full range. I've seen the range from people that come in severely manic with psychosis requiring hospitalization in dire circumstances, who within a year or two are experiencing virtually no symptoms and the fact that they have bipolar disorder would be undetectable by anybody. I've also seen people whose lives are chronically impaired by depression, anxiety, and symptoms of bipolar disorder.
What we know is that in the long-term course of this illness, meaning over a decade or so, the majority of youth with bipolar disorder will experience prolonged symptomatic recoveries at some point. But we also know that they have recurrences and so I think that the perspective I would encourage people to take is that of a chronic disease like you would see with asthma or diabetes. where the goal is to limit the effect that this illness has on people. So that they can go about their lives without suffering and build into their approach plans for recurrences, or relapses and strategies to minimize the impact of those recurrences and reduce their frequency.
I think it's good to be aspirational and aim for no symptoms and for a cure. At the same time if that sets people up for excess pressure on themselves or on their children then that becomes an issue of its own. So, I encourage people to focus on what's within their control, things like attending therapy appointments, taking medication, instituting healthy habits. Because the other point that I would make is that there is some thought that over time people learn skills that it takes to identify early indicators that they're having a recurrence and implementing quick adaptive responses to those, whereas early in the illness people still don't yet know how they're reacting to illness, how illness is manifesting. But over time patterns emerge, and families develop response systems and so the impact of subsequent episodes can be diminished that way.”
8. Is there a minimum age for a bipolar disorder diagnosis?
“The answer to that question is it depends who you ask. I would say that there is not a minimum age. But it's important to keep the perspective of what's the likelihood or frequency of this condition at different ages. So, in the middle adolescent or older adolescent bipolar disorder is about as common as it as an adult.
I think that there are people who don't acknowledge the existence of bipolar disorder in children and I think that that's an extreme perspective. I myself have seen children that meet strict diagnostic criteria for bipolar disorder and respond to the treatments for bipolar disorder. But I've also seen a lot of overdiagnosis if you will. People who have received the diagnosis because there is increased irritability which is especially common in child psychiatric disorders.
So, childhood bipolar disorder in my view does occur but much less frequently than adolescent or young adult bipolar.”
9. Typically, how long does it take for individuals to get a diagnosis of bipolar disorder?
“In part, it depends how they present. If someone has an acute manic episode, it could take a day or two because their symptoms are so severe and so obvious that they necessitate emergency department visits or a similar event. For other people who have somewhat milder symptoms, it can be missed for years. The typical delay from the onset of symptoms of bipolar disorder until an accurate diagnosis and adults is upward of a decade.
And that delay is greater for people who had earlier onset. For those of us who treat youth obviously, they haven't waited a decade. The people that we see who have had the illness for some time before we see them, it is often because they have had hypomanic episodes meaning the same symptoms that I mentioned earlier but not as intense, which are misconstrued as age-related or adolescence related or a return to normal for someone with depression, when in fact, the symptoms are still uncharacteristic of the youth and go well beyond what their normal baseline is.
We also see some people who have had psychosis as a prominent symptom of their mania and as a result are diagnosed with a primary psychotic illness such as schizophrenia. But when you dig into the history, you recognize that there has been mania as part of that psychosis which has a meaningful effect on the accurate diagnosis.”
10.Is there anything else you'd like to share with our audience of parents and providers across Pennsylvania?
“I think the main message that I’ll share is that this is a legitimate medical condition, that runs in families, that’s genetic and environmental, and that requires multi-disciplinary approaches. And in that regard is no different from something like diabetes. And I think that the sooner the world can get to the point that we don't distinguish the value, the importance of these diagnoses, because bipolar manifests in mood symptoms rather than blood sugar changes, the better place the world is going to be for patients and families affected by this condition.”