“Mixed Hypomania” in Children and Adolescents: Is It a Pediatric Bipolar Phenotype with Extreme Diurnal Variation between Depression and Hypomania?

Comprehensive Doctors Medical Group, Inc., USA.
Journal of Affective Disorders (Impact Factor: 3.38). 12/2008; 116(1-2):12-7. DOI: 10.1016/j.jad.2008.10.016
Source: PubMed


Although DSM-IV and the literature on pediatric bipolarity recognize mania and mixed phases neither recognizes states of "mixed hypomania." There has been preliminary presentation of the latter phenomenon in the adult bipolar literature. The authors herein describe this phenomenon in a consecutive clinical series of bipolar children and adolescents.
This exploratory study involved 47 consecutive bipolar patients between the ages of 7 and 17 years presenting to an outpatient clinic. They were evaluated using a structured instrument designed to ascertain the presence of major depressive episodes (MDE), hypomania, mania, psychotic disorders, behavioral disorders such as oppositional defiant disorder and conduct disorder and substance use disorders. We defined mixed hypomania as MDE and hypomania coexisting over at least 2 weeks.
Of 47 patients, 9 girls (42.9%) and 9 boys (34.6%) were bipolar II mixed. This paper focuses on them. The mean ages of the bipolar II girls and boys were 14.3 (1.9) years and 12.0 (3.4) years, respectively (p<0.05, t=2.45, df=17). This mixed subgroup tended to experience rising mood in the evening, often with spikes of euphoria; a history of late afternoon to evening increased talkativeness or pressured speech was common. Some patients exhibited flight of ideas. Psychomotor acceleration, heightened level of energy, and increased goal directed activity between 1900 and 0300 were frequently reported. Retrospectively obtained circadian information revealed, in most cases an age inappropriate phase delay of sleep onset: After falling asleep in the early hours of the morning the patients awoke feeling depressed, lethargic and as if they could sleep throughout much of the day.
Cross-sectional, exploratory study based on a relatively small sample size and in need of replication in other clinical settings.
Mixed hypomania was a common phenomenon in pediatric bipolar II patients. It is apt to go unrecognized in cross-sectional assessments done in the morning or in the early or mid-afternoon. Those with this proposed phenotype would appear "depressed" at these times. Alternatively, what we have proposed can also be described as severe diurnal variation between depression and hypomania in the evening. Further study is required combining 24-hour clinical observation and state of the art technologically derived data.

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    • "A growing body of research indicates that eveningness is linked to affective disorders and to more severe depressive symptoms both in clinical and non-clinical samples. Eveningness has been associated with seasonal affective disorder (Johansson et al., 2003; Lee et al., 2011), unipolar (Drennan et al., 1991; Hasler et al., 2010; Robillard et al., 2013) and bipolar affective disorders (Ahn et al., 2008; Dilsaver & Akiskal, 2009; Giglio et al., 2005; Hasler et al., 2010; Mansour et al., 2005; Robillard et al., 2013; Wood et al., 2009), while amongst unipolar patients those with greater eveningness experience more severe depressive symptoms (Bahk et al., 2014; Chan et al., 2014; Gaspar-Barba et al., 2009). In non-clinical samples eveningness has been related to more depressive symptoms in the general adult population (Konttinen et al., 2014; Merikanto et al., 2015) and in university students (Chelminski et al., 1999; Hirata et al., 2007; Randler et al., 2012). "
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    ABSTRACT: Background: The study aimed to elucidate previously observed associations between morningness-eveningness and depressive symptomatology in university students. Relations between components of depressive symptomatology and morningness-eveningness were analysed. Methods: Nine hundred and seventy-four university students completed Polish versions of the Centre for Epidemiological Studies – Depression scale (CES-D; Polish translation appended to this paper) and the Composite Scale of Morningness. Principal component analysis (PCA) was used to test the structure of depressive symptoms. Pearson and partial correlations (with age and sex controlled), along with regression analyses with morning affect (MA) and circadian preference as predictors, were used. Results: PCA revealed three components of depressive symptoms: depressed/somatic affect, positive affect, interpersonal relations. Greater MA was related to less depressive symptoms in three components. Morning circadian preference was related to less depressive symptoms in depressed/somatic and positive affects and unrelated to interpersonal relations. Both morningness-eveningness components exhibited stronger links with depressed/somatic and positive affects than with interpersonal relations. Three CES-D components exhibited stronger links with MA than with circadian preference. In regression analyses only MA was statistically significant for positive affect and better interpersonal relations, whereas more depressed/somatic affect was predicted by lower MA and morning circadian preference (relationship reversed compared to correlations). Limitations: Self-report assessment. Conclusions: There are three groups of depressive symptoms in Polish university students. Associations of MA with depressed/somatic and positive affects are primarily responsible for the observed links between morningness-eveningness and depressive symptoms in university students. People with evening circadian preference whose MA is not lowered have less depressed/somatic affect.
    Full-text · Article · Feb 2016 · Journal of Affective Disorders
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    • "Compared to classic euphoric hypomanic symptoms recalled by 275 remitted patients with BDII, hypomania with mixed symptoms was characterized by more racing thoughts, smaller increase in goal directed behavior, and greater loss of function. Dilsaver and Akiskal (2009) found a severe diurnal variation in bipolar children and adolescents such that they awoke feeling depressed and lethargic and became hypomanic in the evening, often with spikes of euphoria. Patients presenting with mixed symptoms often represent more complex presentations of bipolar disorder (Bauer et al., 1994; McElroy et al., 1992). "
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    ABSTRACT: Objectives: To compare the efficacy and safety of adjunctive quetiapine (QTP) versus placebo (PBO) for patients with bipolar II disorder (BDII) currently experiencing mixed hypomanic symptoms in a 2-site, randomized, placebo-controlled, double-blind, 8-week investigation. Methods: Participants included 55 adults (age 18-65 years) who met criteria for BDII on the Structured Clinical Interview for DSM-IV-TR (SCID). Entrance criteria included a stable medication regimen for ≥2 weeks and hypomania with mixed symptoms (>12 on the Young Mania Rating Scale [YMRS] and >15 on the Montgomery Asberg Depression Rating Scale [MADRS] at two consecutive visits 1-3 days apart). Participants were randomly assigned to receive adjunctive quetiapine (n=30) or placebo (n=25). Results: Adjunctive quetiapine demonstrated significantly greater improvement than placebo in Clinical Global Impression for Bipolar Disorder Overall Severity scores (F(1)=10.12, p=.002) and MADRS scores (F(1)=6.93, p=.0138), but no significant differences were observed for YMRS scores (F(1)=3.68, p=.069). Side effects of quetiapine were consistent with those observed in previous clinical trials, with sedation/somnolence being the most common, occurring in 53.3% with QTP and 20.0% with PBO. Conclusions: While QTP was significantly more effective than PBO for overall and depressive symptoms of BDII, there was no significant difference between groups in reducing symptoms of hypomania. Hypomania improved across both groups throughout the study.
    Full-text · Article · Mar 2013 · Journal of Affective Disorders
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    ABSTRACT: Sleep problems are an essential part of the current diagnostic criteria for depressive and bipolar disorders in children and adolescents. Whereas many studies have reported subjective sleep problems in youth with depression or bipolar disorder, except for reduced rapid eye movement latency associated with depression, few objective mood-related sleep abnormalities have been consistently identified. Recent technologic advances, such as spectral EEG and actigraphy, hold promise for revealing additional objective disturbances. There are presently few evidence-based published practice recommendations for mood-related sleep problems in youth. In this article, the authors chronologically review research on the phenomenology and treatment of sleep difficulties in youth with depressive and bipolar disorders and present research-based and clinically guided recommendations for the assessment and treatment of these problems.
    No preview · Article · Oct 2009 · Child and adolescent psychiatric clinics of North America
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