Heather is a 51-year-old mother of a 13 year-old daughter, Alex, and a 17 year-old son, Justin. After almost 10 years battling anxiety and depression, interspersed with periods of high energy, elation, and sleeplessness, Heather was finally diagnosed with bipolar disorder. Alex and Justin can recall the early years of their childhood when they did not know on any given week what kind of week it would be for their mother and for them. Fortunately, with appropriate treatment, a combination of mood stabilizing medication and therapy, Heather’s moods—and in turn her life—have stabilized.
In recent years, Heather and her husband, Rick, have been increasingly concerned about their children, and about the possibility that they may have bipolar disorder in the future. Justin has always been an easy-going guy, but he had a month-long depression after a break-up with his girlfriend last year, and since then has had another episode of depression that appeared to come “out of the blue.” Alex has had an anxious temperament since toddlerhood, and in recent years has had pronounced social anxiety and frequent panic attacks. Although cognitive-behavioral therapy has been helpful, she remains with distressing symptoms that impair her functioning. Heather and Rick are concerned, and would like to know more about the risk for bipolar disorder in their children, and whether Heather’s diagnosis weighs into decisions about possible pharmacological treatment for their children’s symptoms.
The above anecdote reflects a common occurrence, as many adults with bipolar disorder have children, and many of those children demonstrate some form of psychiatric symptoms, including anxiety, depression, inattention, or significant irritability and mood swings. Several details of the anecdote are worth highlighting, as Heather’s experience with bipolar disorder was very typical. For example, most people who are eventually diagnosed with bipolar disorder have prior problems with anxiety and/or depression. The average delay between onset of bipolar disorder symptoms and diagnosis and treatment of bipolar disorder is about 10 years, and the earlier the onset of bipolar disorder, the longer the delay. Furthermore, although problems such as anxiety and mood swings are common in teenagers, they are especially common among teenagers whose parents have bipolar disorder. This raises important treatment implications. Whereas standard antidepressants such as Prozac are often effective and generally safe for treating teens with anxiety or depression, antidepressants can occasionally trigger a manic episode in teens and this risk is higher in teens who have a parent with bipolar disorder. The same is true, although perhaps somewhat less so, for ADHD medications such as Ritalin.
This leaves treatment providers, teens, and their families with three main options: 1) “watch and wait” (i.e. no medications); 2) use the same treatment approach that would be used in the absence of parental bipolar disorder; or 3) treat with the same medications one would use if the teen already had bipolar disorder. Each of these options has its benefits and drawbacks. Watching and waiting avoids treatment-related risks, but incurs risk of untreated symptoms and possible progression into bipolar disorder. Using antidepressant or stimulant medications often reduces symptom burden, but incurs the risk of medication-induced mania. Finally, using bipolar disorder medications such as lithium or antipsychotics often improves symptoms, and provides some protection against mania, but incurs increased risk of side-effects including weight gain and other physical problems.
When I work with families in this scenario, I modify my treatment approach in several ways. First, I raise my threshold for prescribing. That is, I encourage therapy as a first-line approach even more so than I do for other patients. Second, I underscore the importance of healthy lifestyle and focus on establishing regular sleep-wake, eating, and exercise schedules. I also underscore the accentuated risk of certain biological and environmental stressors. For example, use of alcohol, marijuana, and other substances, is an especially risky endeavor among teens such as Alex and Justin. Similarly, although family stress is not fun for anyone, it is an especially important aspect of care to consider in this circumstance. Indeed, there is promising evidence that a type of family-focused therapy that targets offspring of parents with bipolar disorder may reduce early mood symptoms by optimizing family communication and problem-solving skills. Third, I provide education about the symptoms of mania (so that families are aware when to seek urgent treatment), and about the natural course of bipolar disorder. I address questions relating to the likelihood of developing bipolar disorder during adolescence and young adulthood for these offspring (about 10-20%), the extent of increased risk for bipolar disorder among teenage offspring of parents with bipolar disorder (10-fold increase), and factors that increase risk of bipolar disorder in this high-risk population (e.g. anxiety, depression, and significant irritability and mood swings).
Bipolar disorder is arguably the most familial psychiatric condition, with up to 90% of the risk for bipolar disorder explained by heritability. As such, teens who have a parent with bipolar disorder have unique assessment and treatment needs. Although the concept of early identification and appropriate treatment preventing bipolar disorder has yet to be conclusively supported by careful research, it most certainly passes the logic test. Taking together what we know and what we don’t yet know, I’m of the opinion that symptomatic teenage offspring of parents with bipolar disorder warrant a careful psychiatric evaluation that addresses all of the above nuances and is customized to the unique needs of these teens.