Bipolar at-risk criteria identify ‘relevant clinical minority’

By Eleanor McDermid, Senior medwireNews Reporter

A set of ultra-high-risk criteria for bipolar disorder identifies a group of help-seeking patients with a high rate of new-onset mania or hypomania over the following year, say researchers.

The team, led by Andreas Bechdolf (Academic Hospital of Charite Medicine Berlin, Germany), previously established the criteria using the “close in strategy”, which “combines clinical and behavioral data as well as genetic risk and the age at the maximum incidence of the disorder.”

The resulting bipolar at-risk (BAR) criteria classify at-risk patients into three groups: subthreshold mania; depression with cyclothymic features; and depression with genetic risk of bipolar disorder.

The researchers identified 59 (10.6%) patients meeting these criteria from a sample of 559 help-seeking people aged 15–24 years, which they say “represents a relevant clinical minority.”

Of the BAR patients, 35 participated in 12 months of follow-up, during which time five (14.3%) converted to first-episode mania or hypomania. By comparison, none of the 35 matched controls who did not meet the BAR criteria met this endpoint. The conversion rate in the BAR group was “clinically meaningful” and up to 100 times higher than the rate reported for the general population, say Bechdolf et al in Bipolar Disorders.

They note that, although not matching the DSM-IV criteria for bipolar disorder, their study endpoint “represents a reasonable time point at which a clinical intervention for manic symptoms may be indicated in a closely monitored cohort, balancing the ethical problems of allowing illness progression and that of too early an intervention.”

Furthermore, four of the five patients who met the mania/hypomania endpoint also met the DSM-IV bipolar disorder criteria, and these conversions occurred despite most patients being offered “intensive psychosocial” treatment during follow-up.

Among the BAR group, most patients met the criteria for depression with cyclothymic features (57.2%) or subthreshold mania (28.6%); all five patients who converted fell into these categories.

Although young, the BAR group “comprised a clinically unwell cohort, as indicated by high rates of unemployment, a high frequency of suicide attempts, high prior hospitalization rates, and one suicide during follow-up”, the researchers comment.

They note that their criteria need validating in other cohorts, adding: “Establishing valid BAR criteria would have the potential to open up new avenues of research into indicated prevention efforts in [bipolar disorder] and may thereby offer opportunities to lessen the severity of, or even prevent, the disorder.”

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