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Traditionally, bipolar disorder has been known to run an episodic course with a generally favorable long-term outcome, although some of the recent studies of adult bipolars suggest that the outcome is poor. At present, data on the course and outcome of juvenile bipolar disorder is limited, but the available data suggest that it runs an episodic course with frequent relapses. Strober et al. followed-up 54 adolescents with bipolar I disorder over a period of 5 years and reported a high rate of recovery (96%) from the index episodes, and a moderate rate of relapse (44%). In the Indian study, 30 bipolar subjects with onset in childhood and adolescence were assessed systematically at baseline and 4-5 years later. All the 30 subjects had recovered from their index episodes without chronicity, a finding similar to that of Strober et al. With regard to relapse rate, the sample had a much higher relapse rate (67%) than reported by Strober et al., but the rate was comparable to those reported in adult studies (82-84). In addition, more than 50% of the sample had two or more relapses. The probability of remaining in remission after 4 years was 33% in the Indian study, whereas it was 58% at the end of 5 years in the study by Strober et al.. An important finding of the Indian study that may have implication in treatment planning was that 90% of the relapses occurred in the first 2 years of recovery from the index episodes. That most relapses occurred within 2 years of recovery strongly supports the need for maintenance treatment not only during this period, but probably also thereafter to prevent relapses. In adults, the duration of the index episode before entry, the severity of endogenous features, and a history of previous episodes predicted a longer time to recovery. However, no predictors of recovery have been identified in juvenile bipolar disorder, although in the study by Strober et al. recovery from the index episode took longer for patients with depression than for either mania or mixed episodes. Similarly, no predictors of relapse have been identified in juveniles. There is some evidence to suggest that adolescents with bipolar disorder may have a more prolonged early course and may be less responsive to treatment, with approximately half of them showing significant functional impairment compared to their premorbid state.
An important issue related to juvenile bipolarity is rapid cycling. Geller et al., in their study of 26 children and adolescents with bipolar disorder, reported rapid cycling in 80% of them and suggest that it is a hallmark of juvenile bipolarity. Interestingly, in the Indian study rapid cycling was observed in only 4% of the subjects. However, rapid cycling has to be assessed carefully, as rapid cycling in both adults and adolescents has been associated with treatment resistance.
Another issue in juveniles which is still unclear is the association between
bipolar disorder-I and bipolar disorder-II. Although the switch rate from bipolar-II
to bipolar-I in prepubertal children has been reported to be low and similar
to that in adults, there is a suggestion that bipolar-II in children might
be an age-specific, developmental precursor to bipolar-I. Adolescents with
bipolar disorder are at increased risk for completed suicides. Strober et al.
reported medically significant suicide attempts in 20% of their adolescent
sample, whereas in the Indian study, suicide attempts were reported in only
3% of the subjects.
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