Did you miss our chat with Christopher Correll? Read the transcript of this exciting and informative chat. To stay informed about monthly Expert Chats and other The Balanced Mind Foundation events, join our mailing list now by entering your email address and zip code in the box in the top right corner of the screen.

Biography Christoph U. Correll, M.D., is a child and adolescent psychiatrist and research scientist. He graduated from the Medical School at the Free University of Berlin in Germany before completing his training in child, adolescent, and adult psychiatry at the Zucker Hillside Hospital and Schneider Children's Hospital, New York. Dr. Correll's primary interest is in the timely identification and treatment of young people who are in the earliest stages of severe mental illnesses, including psychotic disorders. Dr. Correll is a member of The Balanced Mind Foundation's Scientific Advisory Council.

Nanci - The Balanced Mind Foundation    
I am very pleased to welcome our guest today, Dr. Christoph Correll.

Christoph Correll MD
Good morning everybody.

Nanci - The Balanced Mind Foundation    
Could you start out by telling us a little about the Recognition and Prevention program and perhaps some of your current research studies?

Christoph Correll MD    
Ok, I don't want to take too much time because this is more for members to ask questions, but here you go:
The RAP program is an NIMH funded clinical and research clinic that evaluates, treats and follows adolescents and young adults who are thought to be at risk for developing a psychotic disorder. Recently, we have added a high risk component for youth who are thought to be at risk for developing bipolar disorder.

Lisa    
Dr. Correll, in your expert opinion, what would you say are the hallmark signs of early -onset bipolar disorder in children or early adolescents?

Christoph Correll MD    
I am not sure if you mean hallmark symptoms of early-onset bipolar disorder or early onset symptoms before the disorder has started. Can you please clarify?

Lisa 
Hallmark symptoms of the disorder.

Christoph Correll MD    
Well, that is easy because I am of the belief that youth should be diagnosed the same way as adults. That means that the DSM-IV diagnosis criteria need to be met: persistent and abnormal elated mood plus at least 3 B criteria or irritability plus at least 4 B criteria. In youth, the only question is whether the symptoms of full bipolar disorder last shorter because of brain maturational differences, or whether the shorter symptoms are part of a sub threshold disorder that might develop into full bipolar disorder.

Hallmark symptoms include as per Barbara Geller's work (in that they differentiate pretty well from ADHD): Mood elation or grandiosity, decreased need for sleep (not simply insomnia), increased thinking / or flight of ideas, increased energy/goal directed activities and hypersexuality.

Nanci - The Balanced Mind Foundation    
Could you comment on the work underway for the DSM-V and what direction you'd like to see that go as far as defining early-onset bipolar disorder?

Christoph Correll MD
Hmm. This is difficult. I am not really familiar with the DSM-IV developments, as the organizers have so far taken a stance of not sharing much of the process. This has recently invited some criticism, as input from outside might be crucial to the success of the endeavor.

What I do know is that DSM-IV seems to base diagnoses more on longitudinal outcomes and follow up, that dimensional rather than yes/no categorical criteria and assessments/scales might be included and necessary to make a diagnosis and that sub threshold conditions might be defined more explicitly, so that they can be studied.

The potential risk of the dimensional approach and of including sub threshold conditions in a diagnostic manual is the potential to medicalize areas of "normality", which could lead to stigma, changes in self-perception and, possibly, unnecessary treatment.

natg    
Dr Correll, At what age can you determine that it is bipolar disorder? Right now, my son is diagnosed as mood disorder and ADHD. Does it become clearer as the child becomes older?

Christoph Correll MD    
I don't think that there is a specific age when you can or cannot diagnose bipolar disorder in a child. However, it is much easier when the child matures and the brain is closer to what an adult's brain is. In adolescence, the bipolar disorder symptoms are usually clearer. As your child matures, most likely the direction of the symptoms (progression or resolution or change) should become clearer.

lucinda    
Dr Correll - has there been any new research to indicate that early intervention and treatment for bipolar disorder can lead to a more normal adulthood or that early treatment could actually 'cure' bipolar disorder?

Christoph Correll MD    
This is the goal of the early identification and intervention movement and research. However, to date, we only have indirect evidence that early identification and intervention should improve functioning and outcome, simply by mitigation of otherwise impairing symptoms that usually interfere with the normal acquisition of skills. What is still unclear is whether there are critical brain developmental periods that - when helped with through intervention - could alter the underlying biology of a disease process. We clearly need more longitudinal research.

natg    
Dr Correll, Do you feel that antipsychotics alone work effectively for treatment of mood disorders?

Christoph Correll MD    
Yes. The newer, atypical antipsychotics have proven efficacy for mania in youth and in adults. In youth, the effects appear to be stronger and more beneficial than seen with conventional mood stabilizers, although we only have one single, short term real head-to-head comparison study (Seroquel versus Depakote). However, side effects can also be more problematic. This is why the lowest risk atypical antipsychotic(s) should be tried first and why we need more comparative effectiveness research in youth.

Unfortunately, many children and adolescents can not be helped with monotherapy of either lithium, an antiepileptic mood stabilizer or an atypical antipsychotic, and combination treatments are often needed, being more the rule than the exception, both in youth and in adults with bipolar disorder.

Since you were asking about "mood disorders", the issue of antidepressant efficacy of atypical antipsychotics is less uniform. Here Seroquel and, possibly, aripiprazole (Abilify) have the best data for atypical antipsychotics, with even stronger data in unipolar, unresponsive depression. For bipolar depression maintenance, lamotrigine (Lamictal) is a very good option that has also minimal side effects in general.

Nanci - The Balanced Mind Foundation    
Aren't you currently working on a research study on weight gain with atypical antipsychotics? Could you comment on your hypotheses or findings or is it too soon? Weight gain is a significant concern for many of our families considering or using this classification of medication with their children.

Christoph Correll MD    
Yes, this is correct. We enrolled 516 children and adolescents age 4-19 who were started by their clinician for any clinical reason on any of the available atypical antipsychotics. Out of the 516 youth, more than 2/3 were antipsychotic naive, which gives us the chance to look at weight gain and other adverse effects independent of prior medication exposure.

What we found is that in general, kids are more susceptible to many of the antipsychotic side effects than adults. This includes sedation, muscle stiffness, weight gain and lipid abnormalities. They are not at higher risk for short-term glucose abnormalities and akathisia (restlessness).

In youth with prior antipsychotic exposure, the ranking order of weight gain and metabolic risk is similar to that in adults, with Zyprexa being the worst offender. In youth risperidone (Risperdal) seems to cause somewhat more weight gain than Seroquel whereas in adults they are similar. Abilify and Geodon look the best. However, in antipsychotic naive patients (those who never had been on an antipsychotic), all atypicals caused quite a bit of weight gain, particularly early on, The differences in weight gain became more apparent/greatest as treatment progressed for longer than 3-6 months. Importantly, however, although weight gain was substantial in the beginning with all atypicals, they clearly differentiated in terms of metabolic abnormalities. Here, risperidone and, especially Abilify looked the best (we did not have antipsychotic naive youth on Geodon -so we don't know the results there).

emilyfiorite    
Are there any signs of BP that we know of in a typical MRI scan or brain function scan? Some professionals claim that scans can show variations in the brain that can be used for diagnosis.

Christoph Correll MD    
Unfortunately, to date, there are no reliable biological or clinical tests that can predict or verify a diagnosis of bipolar disorder in kids or adults. The same is true for all other psychiatric diagnoses.

Lisa    
Dr. Correll, how does anxiety play a role in neurological disorders, and what are your recommendations for parents to help their children/adolescents?

Christoph Correll MD    
Anxiety is one of the most common psychiatric conditions, in adults and in youth. It is part of the normal human experience, but can get out of hand, get generalized and become interfering.  In youth, anxiety can have multiple reasons, including biological ones and psychosocial or environmental ones. The important thing in kids is that anxiety can mimic other conditions and be mistaken for symptoms of bipolar disorder or, even, psychosis. On the other hand, it can also be a harbinger of early sign of depression or later bipolar disorder or be a comorbidity.

Nanci - The Balanced Mind Foundation    
We had a few questions come in about your discussion of atypical antipsychotics, so I'll try to combine them into one. 1) When using these medications, is it necessary to have regular blood work to monitor metabolic problems; 2) does muscle stiffness tend to go away if the medication is stopped; 3) is any particular atypical antipsychotic better or worse in combination with lithium?

Christoph Correll MD    
OK, these are good questions. Blood / Metabolic Monitoring: Yes, in kids, weight and height should be monitored monthly or at each psychiatrist visit. Blood work for fasting blood sugar and lipids should be performed before or very close to starting an antipsychotic, at 3 months and 6-monthly thereafter. If there is unexplained increased thirst and urination, sedation or somnolence, an extra blood test is needed, as this could be a sign of diabetes.
Muscle stiffness goes away when the medication is lowered or stopped or switched to a lower risk antipsychotic. Abnormal involuntary movements (also called tardive dyskinesia) can be lasting, although the risk in kids seems to be lower (0.4% per year in 783 youth followed for up to a year in a meta-analysis we did recently), and, encouragingly, the symptoms also seem to abate upon stopping the antipsychotic (as kids have more brain receptor reserves than adults).

Antipsychotic combinations with lithium or other mood stabilizers have not been compared directly, so we do not know the answer to this question. However, my philosophy is to try to combine agents with the lowest or, at least, a complementary (opposite) side effect profile. Thus, I would try to avoid adding a more sedating or weight gain producing antipsychotic to lithium.

Nanci - The Balanced Mind Foundation    
Here's one more before we move off of this discussion.

Roberta    
Dr. Correll, I have heard that there is a new antipsychotic now being studied that would have less of these side effects. Have you heard of this?

Christoph Correll MD    
Whenever "new" antipsychotics are studied they are usually touted to have either more or similar efficacy but clearly are safer than previous options. This can not be evaluated until the drug is really used in clinical practice.

Christoph Correll MD    
The newest antipsychotics on the market are Invega (paliperidone), which is basically like Risperdal, as it is its own metabolite and Fanapt (iloperidone), which is like a cross betweeen Risperdal and Geodon, having similar weight gain to Risperdal.

Antipsychotics that might come to the market are lurasidone and asenapine, but they also seem to be similar to the medium weight gain risk agents (Risperdal and Seroquel and Fanapt) that are already on the market.

teddyone    
Do you think that the rages that children with bipolar disorder have tend to decrease more as they age?

Christoph Correll MD    
Yes. As kids grow older, their frontal lobe develops more. The frontal lobe controls our impulses and behaviors. Also, reason and rationality increase with brain maturation. Thus, there is a good hope that the rages improve based on biological processes. In addition, psychosocial interventions can aide this process.

Nanci - The Balanced Mind Foundation    
I think I just heard a collective sigh of relief from our audience!

teddyone    
Do you have any advice for when a child with bipolar disorder is stable on meds and is entering adolescent-teenage years? We've heard that the teenage years are the most difficult time as the child's body is growing and changing so much.

Christoph Correll MD    
Yes, adolescence is a difficult time period in our lives, even under the best of circumstances and even without any added illness. It is hard to predict how the hormonal changes and the increased desire for independence and being "normal" and accepted by peers will interact with the underlying disorder, the need for continued medication treatment, dealing with side effects, etc.

One has to be vigilant for signs of worsening and need to adjust medications, but also not become too controlling and "paranoid" about more "normal" adolescent moods and behaviors, as this runs the risk of pathologizing developmental tasks and getting into a power struggle.

be11e    
What are the chances of a recurring psychotic episode? Our psychiatrist said there is a possibility that my child will not have another psychotic episode. What steps can I take to prevent subsequent episodes? Is there any evidence that a single episode is not a predictor of future episodes?

Christoph Correll MD    
We have very little research on the trajectory and outcomes of psychotic episodes in bipolar disorder. In general the past predicts somewhat the future. Thus, once one had psychosis, it is more likely to have it again compared to when there has never been psychosis. However, there is a good chance that - particularly - when the mood remains stable -  no further psychotic episode will occur.

Preventive measures are the same as for prevention of mania or depression: Stress minimization, sleep hygiene, no night work, no drugs or more than minimal alcohol use.

Mitzi    
Dr. Correll- Do you have any comments on hypersomnia as it relates to either BP or a psychotic disorder? Any ideas on what to do to help this difficult symptom?

Christoph Correll MD    
Hypersomnia can either be symptom of depression or a medication side effect. It is not a typical symptom of mania or psychosis, unless there are negative symptoms of psychosis that are associated with amotivation, etc. If the reason is depression, this needs to be treated. If it is a side effect, the timing and/or dose of the medication might need to be adjusted, or it might need to be switched to a less sedating agent.

Roberta    
Bipolar disorder has been in my family for many generations. Grandparents, mother, father, aunts, uncles, siblings, myself and my daughters. Is it at all possible that my daughters will not pass on this disorder to their children?

Christoph Correll MD    
It is possible, but chances are high that your daughters will have a much-increased risk for having a mood disorder in their life.

emilyfiorite    
We always seem to have a problem with the use of amoxicillin or similar antibiotics. Mood swings are more frequent and much more severe. Is there any indication that these can interfere with mood stabilizers or antipsychotics? In particular, Risperdal and Seroquel?

Christoph Correll MD    
I am not aware of studies that have systematically assessed this. But there have been case reports. The question is whether the medication or the underlying illness that the antibiotic is used for is related to the mood instability.

Nanci - The Balanced Mind Foundation    
We're almost at the end of our hour so let's wrap up with a more global question.

Lisa    
Dr. Correll, please discuss what you believe are the best treatments and course of action parents can take when their child is diagnosed with a mental illness?

Christoph Correll MD    
First, there needs to be a thorough diagnostic assessment to rule out medical causes, substance-related issues or traumatic or stressful events/situations that could be addressed directly. The diagnostic openness and evaluation needs to remain during the entire treatment, as kids develop and their mental disorders or problems can change and morph. Then, psychosocial and psychotherapeutic interventions should be explored and tried.
If this is not helpful enough or if symptoms are too severe to treat with non-pharmacologic measures alone, medications need to be added. Side effects and efficacy need to be monitored closely and the medication(s) with the best efficacy and lowest side effect profile in a given person are to be favored. This might take several trials (and errors) until one gets there. Usually maintenance treatment is needed.

The question as to when to decrease medication doses or stop medication(s) is very difficult to answer. Usually, after only one episode, one could wait for a 1 year period of full recovery, both symptomatic and functionally, with return to the pre-illness onset baseline. If a second episode of mania occurs, very long maintenance is usually needed, If there is a strong family history, one might not even want to withdraw meds after the first episode.

Nanci - The Balanced Mind Foundation
Dr. Correll, we can't thank you enough for sharing your time and expertise. We covered a wide array of topics and I think I speak for our members when I say that I learned a great deal from you. We very much appreciate your dedication and work to helping our children.

Christoph Correll MD
Thank you very much for inviting me into your chat room. It was a pleasure discussing very difficult but pertinent issues with you, and I hope that this discussion has been somewhat helpful.