User:Ongmianli/PBD Portfolio

=Pediatric bipolar disorder (description, assessment and diagnosis)=

Identifying bipolar disorder in children is challenging at any age because youth diagnosed with bipolar disorder frequently have depressive and manic symptoms that occur daily, and sometimes simultaneously.

Therefore, the purpose of this page is to provide an up to date resource for clinicians on pediatric bipolar disorder (PBD) with regard to base rates, recommended diagnostic interviews, screening instruments, process/outcome measures, change benchmarks of clinical significance and resources available online and in the community.

Overview
Pediatric bipolar disorder (PBD) is characterized by extreme fluctuations in mood or emotional dysregulation that ranges from mania (as shown by displays or feelings of extreme happiness, unrealistic overachievement and anger), to depression (as shown by displays or feelings of sadness, changes in appetite or weight and irritability  . It is important to note that these moods exceed normal responses to life events, represent a change from the individual's normal functioning, and cause problems in daily activities. These mood fluctuations result in a child finding it difficult to live with family, friends and teachers when it was previously not an issue.

Diagnostic changes
The diagnostic criteria for bipolar disorders changed slightly from DSM-IV to DSM-5. Summaries are available here and here.

Description
People with bipolar disorder experience unusually intense emotional states that occur in distinct periods called "mood episodes". An overly joyful or overexcited state is called a manic episode, and an extremely sad or hopeless state is called a depressive episode. Sometimes, a mood episode includes symptoms of both mania and depression.

People with bipolar disorder also may be explosive and irritable during a mood episode. Extreme changes in energy, activity, sleep, and behavior go along with these changes in mood. It is possible for someone with bipolar disorder to experience a long-lasting period of unstable moods rather than discrete episodes of depression or mania. . A person may be having an episode of bipolar disorder if he or she has a number of manic or depressive symptoms for most of the day, nearly every day, for at least one or two weeks. These debilitating symptoms can result in an afflicted individual to be unable to function adaptively in several settings.

Demographic information
This section describes the demographic setting of the population(s) sampled, base rates of diagnosis, country/region sampled and the diagnostic method that was used. Using this information, clinicians will be able to anchor the rate of PBD that they are likely to see in their clinical practice.

Base rates in different clinical settings

 * KSADS = Kiddie Schedule for Affective Disorders and Schizophrenia,
 * WASH-U = Washington University version, -PL = Present and Lifetime Version, -E = Epidemiological version of the KSADS
 * LIFE = Longitudinal Interval Follow-Up Evaluation,
 * DICA = Diagnostic Interview for Children and Adolescents

Brief screening tools
The following are brief screening tools that typically takes less than 5 minutes to administer to accurately diagnose pediatric bipolar disorder:

7 Up 7 Down Inventory (7U7D)
The 7 Up 7 Down Inventory is a recently developed and validated questionnaire with 14 items of manic and depressive tendencies carved from the General Behavior Inventory, a well-validated but cumbersome interview. For both mania and depression factors, 7 items produced a psychometrically adequate measure applicable across both aggregate samples. Internal reliability of the Mania scale was .81 (youth) and .83 (adult) and for Depression was .93 (youth) and .95 (adult).

The 7 Up 7 Down Inventory, along with the accompanying research article can be found here.

PGBI-10M
The PGBI-10M is a brief (10 item) instrument derived from the Parent General Behavior Inventory (P-GBI), a 73-item mood inventory, to assess mania in a large sample of outpatients presenting with a variety of different DSM-IV diagnoses, including frequent comorbid conditions.

The 10-item GBI derived from the 73-item P-GBI had good reliability (alpha = .92), correlated (r = 0.95) with the 28-item scale, and showed significantly better discrimination of bipolar disorders (area under the receiver operating characteristic [AUROC] curve of 0.856 vs. 0.832 for the 28-item scale, p < .005). The 10-item scale also did well discriminating bipolar from unipolar (AUROC = 0.86) and bipolar from attention-deficit/hyperactivity disorder (AUROC = 0.82) cases.

The full version of the scale, the Parent-General Behavior Inventory (P-GBI) is a parent report measure of depressive and hypomanic/biphasic symptoms adapted from the General Behavior Inventory (GBI).

Classification rates exceed 80%, and receiver operating characteristic analyses showed good diagnostic efficiency for the scales, with areas under the curve greater than .80. Results indicate that clinicians can use the parent-completed GBI to derive clinically meaningful information about mood disorders in youths.

Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime (KSADS-PL)
The Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime (KSADS-PL) is a semi-structured diagnostic interview that assesses current and past Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition (DSM-IV-TR) Axis I psychopathology in youth. The KSADS-PL diagnostic interviews have good inter-rater (.93 to 1.00) and retest reliability (.77) for mood disorders Here is a link to a PDF of the diagnostic interview for the Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime.

Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS)
The Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia(WASH-U-KSADS) was expanded from the 1986 version of the KSADS, which was modified and expanded to include onset and offset of each symptom for both current and lifetime episodes, expanded prepubertal mania and rapid cycling sections, and categories for attention deficit hyperactivity disorder and other DSM-IV diagnoses. To optimize diagnostic research, skip-outs were minimized.

The kappa values of comparisons between research nurse and off-site blind best-estimate ratings of mania and rapid cycling sections were excellent (0.74-1.00). High 6-month stability for mania diagnoses (85.7%) and for individual mania items and validity against parental and teacher reports were previously reported.

The link to the diagnostic interview for the Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia can be found here.

Overview
The purpose of this subsection is to use Baynesian probability theory in order to accurately predict the diagnosis of pediatric bipolar disorder, given base diagnosis rate in the region and diagnostic likelihood ratios.

Area under curve (AUC)
The area under the curve (AUC, or AUROC) is equal to the probability that a classifier will rank a randomly chosen positive diagnosis of PBD higher than a randomly chosen negative diagnosis of PBD.

Likelihood ratios
Likelihood ratios (also known as likelihood ratios in diagnostic testing) are the proportion of cases with the diagnosis scoring in a given range divided by the proportion of the cases without the diagnosis scoring in the same range. The table below shows area under the curve (AUCs) and likelihood ratios for potential screening measures for pediatric bipolar disorder. It should be noted that all studies used some version of a K-SADS interview by a trained rater, combined with review by a clinician to establish consensus.

"LR+" refers to the change in likelihood ratio associated with a positive test score, and "LR-" is the likelihood ratio for a low score. Likelihood ratios of 1 indicate that the test result did not change impressions at all. On the other hand, likelihood ratios larger than 10 or smaller than 0.10 are frequently clinically decisive, 5 or 0.20 are helpful, and between 2.0 and .5 are small enough that they rarely result in clinically meaningful changes of formulation.

Area under curve (AUCs) and likelihood ratios
The following table describes the diagnostic likelihood ratios and area under curves for the top pediatric bipolar disorder measures.

Clinically significant change benchmarks
Listed below are clinically significant change benchmarks of common screening instruments used for pediatric bipolar disorder.

Treatments
Wikipedia has a page reviewing treatments for bipolar disorder (Treatment_of_bipolar_disorder -- need to figure out if links need to be formatted as internal or external, depending on where we host this). Effective Child Therapy provides a curated list of effective psychosocial treatments for bipolar disorder in youths.

Community resources

 * National Alliance on Mental Illness - the nation’s largest grassroots mental health organization dedicated to building better lives for the millions of Americans affected by mental illness. NAMI advocates for access to services, treatment, supports and research and is steadfast in its commitment to raise awareness and build a community for hope for all of those in need.
 * Balanced Mind Foundation – information, articles, parent support chat rooms.
 * Effective Child Therapy – Information and articles curated by Society of Clinical Child and Adolescent Psychology (SCCAP), a division of the American Psychological Association.
 * International Bipolar Foundation - Information, help and resources available for caregivers and those afflicted with bipolar disorder.
 * Bipolar Network News - an online clearinghouse and information on latest treatments, research and psychoeducation about mood disorders
 * Depression Alliance - a United Kingdom charity that works to prevent and relieve depression by providing information and support services via supporter services, publications and self-help groups.
 * Depression and Bipolar Support Alliance (DBSA) - a peer-directed national organization that provides links to resources, support groups, and peer support for individuals and their families suffering from bipolar disorder.