Did you miss our chat with Dr. Boris Birmaher? Read the transcript of this exciting and informative chat. The Balanced Mind Foundation will be hosting several more expert chats this Spring. Watch your email for more details.

                                       Biography

Dr. Birmaher is the director of the Child and Adolescent Anxiety Program and co-director of the Child and Adolescent Bipolar Services at Western Psychiatric Institute and Clinic of UPMC. He also serves as endowed chair in Early Onset Bipolar Disease and professor of psychiatry at the University of Pittsburgh School of Medicine. Dr. Birmaher is the author of New Hope for Children and Teens with Bipolar Disorder, which can be ordered from our bookstore. In addition to his book, Dr. Birmaher has also published over 200 research articles in peer reviewed journals. 

Nanci - The Balanced Mind Foundation      

Dr. Birmaher, could you start out by telling our visitors a bit about the programs that you oversee? 

Boris Birmaher MD     
We have a clinic that focuses only on children with bipolar disorder. Also, we have several ongoing studies that range from symptoms of bipolar to treatment and MRI.

Also, we have a consultation service for kids with difficult to diagnose and treat problems or that the parents want to rule out bipolar disorder- this program accepts children from all USA and the world. 

Susan     
I've been told that "kids" can sometimes outgrow bipolar condition. Have you found this in your experience to be the case? Is it more that as the kids mature they become better able to handle their situation but still need to maintain meds., etc.? 

Boris Birmaher MD     
A true diagnosis of bipolar is for lifetime. However, since we still need to learn a lot about bipolar in children, it is possible that some children will improve with time- the same happens with epilepsy and depression. 

Mitzi     
Do you recommend MRIs for diagnosis?  All my doctors say it isn't necessary. 

Boris Birmaher MD     
At this moment it is not necessary- we request an MRI when we suspect that there is another neurological illness that may explain the symptoms of the child. All the new functional MRIs are only for research. Some people are claiming that they can do the diagnosis with fancy MRIs. However, this is not accurate yet (I wish this was true).

Nanci - The Balanced Mind Foundation     
Have you had any experience with QEEGs as a part of the diagnostic puzzle? 

Boris Birmaher MD     
Unfortunately, EEGs do not help yet.

janzy     
It seems that a lot of kids with mood disorders struggle socially and do not really have any close friends. What have your observations been in this area and do you have any recommendations for how to cope or what has been helpful?

Boris Birmaher MD     
Some children with depression do not have friends (or have problems with their friends because they do not have motivation, are irritable or aggressive). Also, when they are manic or hypomanic they can be too intrusive and disruptive. For these children the first step is to treat the mood problems. 

Also, some children with mood problems have other disorders like ADHD. The ADHD may interfere with their ability to make or maintain friends; in this case the ADHD needs to be addressed. In other cases, the child has problems with social cues or making friends for other reasons- these reasons need to be investigated and addressed individually. 

Nanci - The Balanced Mind Foundation     
Once the mood disorders are addressed, do you find that in general the social problems improve or do you find that the kids are lacking in social skills because of the amount of time they have been unstable and unable to develop those skills? I realize that's sort of a 'which came first, the chicken or the egg' type of question, but this is a big concern for many of our families. 

Boris Birmaher MD     
Good point- if the child has been depressed for long time, he/she did not have the chance to develop good social skills and we need to help them (similar to a rehabilitation program of a child that has, let say, a broken leg for long time and now he/she is ready to start walking again). However, be sure that the social problems are due to the mood problems and not other causes such as ADHD, anxiety etc. 

cello     
Do you have advice for parents on how to address springtime mania or hypomania?   

Boris Birmaher MD     
Be sure that the medications are in good levels before spring.  If every spring the person gets manic or hypomanic, sometimes you have to temporarily increase the dose of some medications and be sure that the person is not taking medications that can trigger mania or hypomania (e.g., the antidepressants).

sunwillshine     
I just read that your university is researching using Interpersonal and Social Rhythm Therapy to delay or even prevent onset of bipolar in children at risk. I haven't heard of that therapy before; what's it based on? Is this something parents should read up on, or wait till the jury's in? 

Boris Birmaher MD     
I suggest waiting. Basically, some people think that an irregular schedule, going to sleep too late, sleep deprivation etc can trigger mania or make the mood very labile. In these cases, if you regulate your time, schedule etc. you may prevent future episodes of mania or hypomania. There are studies in adults, but not in kids.

janzy     
What is your approach to treating the many symptoms of bipolar disorder? Do you find it generally necessary to medicate for such things as anxiety or sleep problems, or do you recommend sticking to mood stabilizers and other more 'traditional' medications for bipolar disorder. 

Boris Birmaher MD     
For a child with a real bipolar disorder- first, stabilize his/her mood. Then, manage the other symptoms. I prefer to try common sense treatment for the sleep problems (regulate the schedule). For anxiety I like to try first cognitive therapy (if the anxiety is affecting the child's functioning). If therapy does not work, you can try specific medications for these problems. 

marybee     
How often do you find kids to be co-morbidly on the autism spectrum? 

Boris Birmaher MD     
Our clinic specializes in bipolar, then we often see children that have been referred to rule out bipolar, but they end having autistic kind of symptoms and not bipolar- in our BP studies, about 1-2%. 

Mitzi     
Do you see any correlation between BP and sleep disorders? 

Boris Birmaher MD     
Yes, I do. However, remember that one of the symptoms of mania or depression is a sleep problem. 

Susan     
Have you used LENS (Low Energy Neuro Stimulation) for cases with bipolar and ADHD? What are the benefits and risks? 

Boris Birmaher MD     
I do not know the LENS or have seen studies that probe that it works.

Nanci - The Balanced Mind Foundation     
We have a few therapy related questions, one of which I believe ties into a research article you wrote with Dr. Miklowitz on Family Focused Therapy. 

Susan     
Do you find that the entire family typically needs some type of therapy/treatment? 

Boris Birmaher MD     
Like in many medical illnesses, and in particular mental health problems- family education and therapy helps. In our studies with family focused therapy we found that adolescents who received this type of treatment plus medications were less likely to have depressive episodes. 

Mitzi     
What about psychotherapy in general?  We've been doing that for years and it seems to have very little effect.  What seems to really help is the medication. 

Boris Birmaher MD     
There are many types of psychotherapy (it comes in many different flavors and colors). What we currently know is that psychotherapy alone does not work for bipolar disorder. However, certain type of psychotherapies in combination with medications may help a lot.
 
For example, cognitive behavior therapy can help for depression and anxiety (these problems usually go hand by hand with bipolar disorder). Behavior therapy can help for the oppositional problems and ADHD. Something called dialectical behavior therapy can help for mood lability, impulsive behaviors and suicidal tendencies and as we discussed before family therapy can also help.

Nanci - The Balanced Mind Foundation     
I’d like to go back to the LENS question briefly. Susan said that it was recommended when a person was particularly stuck in a depressive state. I wonder if this is the same or similar to Deep Brain Stimulation (DBS)?  Are you familiar with that treatment approach? 

Boris Birmaher MD     
Sorry, but I do not know- DBS is an invasive treatment for people with severe resistant depression- it requires surgery and the implantation of electrodes in certain places in the brain- it has not been used in children or teens and not in people with bipolar.

Cindy     
How does bipolar generally present as an adolescent, say 14 or older, as opposed to a younger child? 

Boris Birmaher MD     
Good question that requires a long answer. However, in a nut shell: the older the child the more typical the symptoms of depression and mania. The younger the child the more difficult to ascertain symptoms (e.g., it is difficult to know what pathological elation and grandiosity are in very young children). Young children tend to have more mood swings and less typical symptoms. Also, they have more symptoms of ADHD and behavior problems that may confuse the clinical picture.

scart89     
Dr. Birmaher, I have not read your book, but I've read about it. If you had to summarize your research, what have you discovered which inspires the most "new hope" for pediatric bipolar patients? Can you offer an overview? 

Boris Birmaher MD     
Great question- we are  improving the way we are making the diagnosis, having more research regarding treatments, people are more aware that children may have bipolar and receive more specific treatments earlier. In the past, people waited on average of 10 years to have the correct diagnosis and the best available treatments. Thanks to parents like you and organizations like The Balanced Mind Foundation the public is more aware and NIMH is allocating more funds for research. 

Pat O     
Do you ever see incredibly restless sleep (leg kicking, teeth grinding, shouting) during sleep with kids with bipolar? We have situation where the child is too anxious to sleep alone but this behavior is often painful for us when we sleep in the same bed. 

Boris Birmaher MD     
Restless sleep is not specific to bipolar- it can be many other things like "restless leg syndrome". Also children with separation anxiety disorder have a hard time sleeping by themselves. There are great psychotherapy treatments for separation anxiety. 

Nanci - The Balanced Mind Foundation     
We have a few questions about anxiety that I'd like to blend together since we're near the end of our hour. 

Boris Birmaher MD     
ok with me.

Nanci - The Balanced Mind Foundation     
With your experience as the director of the anxiety clinic I'm sure you can share a lot of good information. From your experience, does anxiety stem from depression, mania or both. And how does one best treat it when a child with BP may not be able to tolerate SSRIs or respond to traditional anti-anxiety medications. 

Boris Birmaher MD     
A large proportion of children (and adults) with bipolar have anxiety problems- we do not know why. But all the studies show the same results- there are two treatments for anxiety 1) cognitive behavior therapy (CBT) and 2) medications, mainly the SSRIs (although medications like Ativan can also help). Recent studies have shown that the combination of CBT and meds works the best.
 
If a child has good treatment for his/her bipolar symptoms- you can try the SSRIs. If the child does not tolerate one SSRI try a different one. Start with lower dosages and increase them very slowly. Another option is to try first CBT alone. 

Nanci - The Balanced Mind Foundation     
Dr. Birmaher, thank you so much for sharing your time and expertise. We covered a wide range of topics and I know that our families really appreciate the opportunity to be able to ask you questions. 

Nanci - The Balanced Mind Foundation     
And thank you for all the work you provide to families and to The Balanced Mind Foundation. 

judy     
Thank you so much Dr. Birmaher 

Cindy     
Yes!  Thank you!! 

Boris Birmaher MD     
You are welcome- I hope all your children will feel well soon.