Did you miss our chat with Ellen Leibenluft, M.D.? Read the transcript of this exciting and informative chat. The Balanced Mind Foundation will be hosting several more expert chats this Spring. Stay informed- join our mailing list by entering your email address and zip code in the box in the top right corner of the website.

Biography
Dr. Leibenluft is Chief of the Unit on Affective Disorders in the Pediatrics and Developmental Neuropsychiatry Branch, Mood and Anxiety Disorders Program, National Institute of Mental Health. She received her B.A. from Yale University in 1974 and an M.D. from Stanford University in 1978.  She is now actively involved in research on bipolar disorder in children and adolescents, with a particular emphasis on differences between children and adults in the presentation of the illness; neural mechanisms underlying the symptoms of the illness; and the development of new treatment strategies for early-onset bipolar disorder. 

Nanci   
We are very excited to have Ellen Leibenluft, MD as our guest for this months’ The Balanced Mind Foundation expert chat. Dr. Leibenluft is a Senior Investigator and Chief of the Section on Bipolar Spectrum Disorders with the National Institute on Mental Health. Her research focuses on the brain mechanisms involved in bipolar disorder in children and adolescents and on diagnosis. If you are interested in participating in an NIMH research studies or just want more information, be sure to visit this webpage: http://www.thebalancedmind.org/connect/find and search for "Research Studies"  or call the recruitment line phone number:  301-496-8381.

Ellen Leibenluft MD    
It's a pleasure to be with you all.

Nanci    
Dr. Leibenluft, it's been a year and half since we last chatted with you, would you like to update us on what's going on at the NIMH.

Ellen Leibenluft MD
Sure. We've been very busy continuing along with our ongoing studies and starting some new ones. In terms of the ongoing studies, for almost a decade now we have been studying youth with bipolar disorder (BD) and those with severe mood dysregulation (SMD).

SMD is a clinical syndrome we defined to try to address the controversy about whether children with very severe irritability, but without the distinct manic episodes that are characteristic of bipolar disorder (BD), should be considered to have bipolar disorder. We have found differences between BD and SMD in what tends to happen to them when they grow up, family history, and brain function.

We are continuing these studies, comparing children with SMD and BD on brain function in particular, using neuroimaging. We have also started new treatment trials, both for youth with SMD and those with BD. And, finally, we have started a study of children with a family history of bipolar disorder (that is, children with a parent or sibling with the illness). So as you see we have been very busy.  

Nanci    
Before we start taking questions, (and please feel free to submit them at any time) could you go into more detail about the differences you are finding with SMD and BP?

Ellen Leibenluft MD    
As children with SMD grow up, they appear to be at risk to develop depressive disorders and anxiety disorders, but not mania (in other words, not bipolar disorder). That's probably the most important difference, and it raises the question as to whether the treatment should be different between the two groups.

Nanci    
That was going to be my next question! What is your assessment of irritability as a symptom, as well as rage?

Ellen Leibenluft MD    
Irritability is very common in children with SMD and in those with BD. The difference is that, with SMD, the irritability is there pretty much all the time. With BD, there may be irritability, but there are also definite periods of time, lasting for at least a few days, when the child is much more active than usual, much happier than usual, different sleep and activity patterns, etc.

So with an SMD child "what you see is what you get," the child looks pretty similar year after year (very irritable, kind of sped up). In BD, there are clear periods that you can point to where the child was different, in terms of their activity level and mood, either up (manic) or down (depressed), and those periods lasted for at least a few days.

Nanci    
Does depression come into play with SMD?

Ellen Leibenluft MD
Excellent question. Yes, a certain percentage (maybe 15%) of the youth we see with SMD have already had an episode of depression. But what we find is that, as they get older, they are at increased risk (relative to children without SMD) to develop depression. So both SMD and BD develop depression, but only BD develops mania.

Nanci    
As a parent, I have to say a huge thank you to you for doing this research. So many of our families are caught in this quandary over diagnosis.

Ellen Leibenluft MD    
You are so kind!! It’s comments like that that keep me (and my team) going. It takes a team of course.

Nanci    
Well, our questions are pouring in so let’s get started . . .

lindad   
So, in a child with bipolar disorder the mania is actually an elevated mood vs. irritability? I have been led to believe that irritability is a child's way of manifesting mania.

Ellen Leibenluft MD   
Great question again. About a decade ago, researchers started suggesting that mania manifests in children as irritability, not euphoria, and that children with BD don't have episodes...instead, what children with BD have (the argument went) was very severe irritability, without episodes of mania like what you would see in adults.

It was to address that question that we defined the SMD group, and started recruiting them and comparing them to children with clear, episodic mania. Most children with clear, episodic mania have euphoria during at least one of their manic episodes. By "most" I mean 85%.   But what we have found is that SMD differs from BD, in terms of what happens to them when they grow up, and in terms of family history and brain function. So our data indicate that irritability, without clear manic episodes, is not the way that children manifest BD.  

Cindy    
Can you talk what is happening when a very anxious or depressed child is treated with an SSRI medication to address those symptoms and then develops many of the more expected signs of mania such as grandiosity, hypersexuality, severe rages, excessive motor activity, and decreased need for sleep?

Ellen Leibenluft MD    
There are several sorts of problems that children can develop when they are treated with SSRI. A relatively rare one is to develop a true manic episode that has all the symptoms of mania and lasts for at least a few days, usually even longer, even after the medication is withdrawn.  Most people think that sort of reaction is an indication that the person has BD, and may develop more manic episodes even without a medication tipping it off.

What's much more common, however, is an "activation" response, which is different from a true mania. It’s much more short-lived, hours or maybe a day or so, resolves quickly, and often doesn't recur if the medication is restarted, at a lower dose, or a different SSRI is used.

So it's very important to distinguish between mania from an SSRI, vs. activation from an SSRI, because in the first instance you would avoid SSRIs, and in the second the child might ultimately do well on them.  

Jessica    
How can we encourage more cooperation between psychiatry and neurology? In the category of SMD kids there are some (like mine) who turned out to have not bipolar disorder but undiagnosed neurological dysfunction--temporal lobe epilepsy. Neurologists have become very aware of the effect on mood that seizures have…yet as far as I can tell, psychiatrists are not looking for a neurological etiology when they see a patient with atypical bipolar symptoms.

Ellen Leibenluft MD    
That's also an excellent question. Often an important link in that chain is the pediatrician. Psychiatrists should talk with the child's pediatrician, and the pediatrician can be thinking about whether a neurologist should also be brought in. If things aren't going well, it's very appropriate to ask your pediatrician to call the psychiatrist, or vice versa.

Robin    
How is ADHD with irritable depression different from bipolar disorder in children and can stimulants and/or SSRIs exacerbate or bring on bipolar disorder in at risk children.

Ellen Leibenluft MD    
ADHD with irritable depression differs from bipolar disorder in that in ADHD with irritable depression there are no manic episodes. A manic episode should be a distinct "up" time, with decreased need for sleep, grandiose thoughts, increased activity, and other symptoms. In ADHD with irritable depression, there may be a distinct "down" time, but there isn't a distinct "up" time.  

I realize I didn't answer the second question. It is very controversial as to whether stimulants or SSRIs can exacerbate or bring on mania in at risk children. I assume we're defining "at risk" as with a parent or sibling with BD. It's important to remember that most people with a sibling or parent with BD don't themselves develop BD. In fact, the most common mood disorder in the families of people with BD is not BD, but unipolar (major) depression.

So we don't withhold treatment with stimulants or SSRIs from at risk children (if it's indicated), but we are very careful about dosing and we follow them closely.

Mimi    
Do anti-psychotic medications work for both bipolar disorder and severe mood dysregulation?

Ellen Leibenluft MD    
Unfortunately we have very little data on what works for SMD because it was so recently defined (we know that antipsychotic medications work for BD). Because children with SMD have ADHD, and often have anxiety, we actually usually start their treatment with stimulants and an SSRI (which you wouldn't use in BD!). We do it slowly and carefully, and we find that many children respond well. We prefer not to start with antipsychotics because they tend to have worse side-effects than stimulants and SSRIs. However, there are 2 other important things to say.

1) Sometimes children don't respond to SSRIs and stimulants, and then we do treat them with a low-dose antipsychotic, and 2) what I am telling you is based on clinical experience, not a clinical trial. We are currently conducting a clinical trial of SSRIs and stimulants in youth with SMD, and if you are interested in participating you can call our referral line to learn more.  

Nanci    
I'll post the link and the phone number again at the end of our chat. We have several questions on teen issues and a general one that I'd like to put through so that we can cover a range of topics.

Belle
What are your thoughts on the 9/29/09 study published in Journal of Abnormal Psychology; "Are There Developmentally Limited Forms of Bipolar Disorder?" MU researchers found an age gradient to indicate young adults may outgrow bipolar disorder.

Ellen Leibenluft MD    
Yes, there is a possibility, and this points out how little we know about the course of these illnesses. But there are two things to be aware of in terms of that article.

First, the design of the study wasn't longitudinal. In other words, they didn't follow a group of people with BD over time and see if it went away. Instead, it was a cross-sectional design...they compared rates of the illness in people aged 20-25 (something like that, I don't remember the exact ages but you get the idea), to people aged 25-30, etc etc. Often, studies that use cross-sectional designs to try to address longitudinal questions don't pan out when someone actually does the longitudinal study.

The other important thing is that this was an epidemiological study...it looked at people in the community, not people in clinics. While that is a very important design to answer many questions, it means that the assessments are done by trained lay people, not clinicians.

As we all know, it is difficult to diagnose BD, especially in young people. The authors do address that issue in the paper, but it still does concern me. And, as I said, the cross-sectional issue is a big one. So the answer is we don't know, and we need to do the longitudinal study.

We follow our youth with BD, and our youth with SMD, longitudinally, and we are very grateful to the parents and children who work with us on that, because longitudinal studies are very difficult to do.  

Robin    
How does a doctor test for bipolar disorder in teenagers? Teens are known for mood swings.

Ellen Leibenluft MD    
Again great question. First, remember that depression and mania aren't just about mood. When someone is manic or depressed, their sleep pattern changes, their activity levels change, thought patterns change, eating, etc etc.

Second, the changes should be much more extreme than what one usually sees in a teenager. And, third, the teen is having trouble.

People around the teen, people like teachers and coaches (and child psychiatrists) who spend lots of time with teens say, gee, this isn't the usual thing. But remember, it's not all about mood...it's about these other things changing too, and staying "abnormal" for a while, not fleetingly.

Cindy    
Is it possible to achieve long term stability with medications? If so, is there a prescribed time that a child or adolescent should take medications once stability is achieved?

Ellen Leibenluft MD    
Yes, it is possible to achieve long term stability with medications. Certainly it is not uncommon for adults with BD to do so...we know less about children, but some do.

The question as to how long to stay on the medication is one which has to be very individualized. It depends in part on how sick the child got when he or she was ill, how many episodes he or she had, how much stress he or she is under, and other factors. And, if the child is withdrawn from medications, it should be done slowly, under close supervision, so that medication can be restarted if symptoms start coming back.

Nanci    
Along those lines of stability in kids vs. adults, do you see any difference in the amount of cycling or stability once kids are through puberty?

Ellen Leibenluft MD    
Another great question. We don't yet have enough long-term data to address that question systematically, so I don't think I can answer that yet. Maybe by the next chat!

Nanci    
Ah, can I take that as a commitment to doing another chat with us?!

Ellen Leibenluft MD    
Of course!! Love talking with you all.  

Charlie

Is anyone anywhere close to using neuroimaging to help with diagnosis in a clinical setting and not just for research.  It is such a guessing game, especially when multiple issues may be going on....

Ellen Leibenluft MD    
Certainly neuroimaging can not yet be used to help with diagnosis...yet. I don't know how long it will be, but it will be a number more years. But eventually we do hope that neuroimaging might aid in the process.

It will never replace careful clinical assessment, but it probably at some point will supplement it. But the other important thing to remember about neuroimaging is that, the more we learn about the brain mechanisms underlying the illness, the more new potential targets we have for treatment. So that's another very important reason why we do neuroimaging studies.

Che'   
This is a two part question: How long does it generally take for doctors to actually find the correct combination of medication to help? My son currently takes 3 types or classes of meds but now that he has gained so much weight from one of them, they don't seem to work now. How do we combat the weight issue when it's caused by medications?

Ellen Leibenluft MD    
In terms of how long it takes, that's very individual and really depends. Some are lucky and find ones more easily, and others it’s a longer and more frustrating road. In terms of combating the weight issue, the usual interventions involve dietary management (meeting with a nutritionist to see some ways to make that work) and exercise.

It's very tough, unfortunately. There are some medications that people think might help with the weight gain but a) it's not clear they do and b) they have their own side-effects.  

Nanci    
This hour went by incredibly fast and we had so many more questions than we could cover so I look forward to you coming back again.

Ellen Leibenluft MD    
For me too. You folks are wonderful.

Nanci    
First, a huge thank you to Dr. Leibenluft for sharing your time and expertise and for working so hard to help our children. Second, here is the link and phone number:

If you are interested in participating in an NIMH research studies or just want more information, be sure to visit this webpage http://www.thebalancedmind.org/connect/find and search for "Research Studies",  or call the recruitment line phone number:  301-496-8381.

Thank you so much, Dr. Leibenluft for your time.

Ellen Leibenluft MD    
And I want to thank everyone for your questions tonight, and for working with us in the research. Obviously, we all have to work together to learn as much as we can to the children as much as we can. It's an honor to partner with you are...we are grateful to you for letting us into your lives in the way that you do.