Pediatric Bipolar Disorder: A Global Perspective

The psychiatric disorder formerly called manic depression has been recognized for hundreds of years. Referred to as bipolar disorder since 1980, it is a serious, chronic disorder that usually begins after puberty. The disorder is characterized by episodes of significant depression and its seeming antithesis, mania, usually sustained for weeks to months. If depression is sadness, underactivity, and unwarranted pessimism, mania is expansiveness, greatly increased energy, and undeserved optimism and grandiosity. An irritable, labile mood often characterizes both mood states. Medications to treat mania and depression as well as prevent future episodes have provided an incentive to better recognize the condition and its nuances, with the hope that treatment will diminish its morbidity and mortality.

As part of the effort to identify bipolar disorder, researchers, especially in North America, have focused their efforts on prepubertal children. For a variety of reasons, divergent views of how the condition should be defined have developed. The modified description of pediatric bipolar disorder, as outlined in the first chapter of Pediatric Bipolar Disorder: A Global Perspective, includes a chronic irritable mood, explosive rages called “affective storms,” chronic overactivity and talkativeness, and mini-episodes lasting for minutes to hours rather than weeks. The result is a controversy within and outside the United States about whether this so-called pediatric form of bipolar disorder is simply the adult disorder beginning early, a separate condition related to the bipolar spectrum, or a completely different condition related to attention deficit hyperactivity disorder, other psychiatric disorders, or both. There are many stakeholders in this controversy, including parents, drug companies, clinicians, researchers, and publishers. The importance to the children themselves, of course, is that appropriate diagnosis, whether it is bipolar disorder rather than something else—or vice-versa—will lead to more appropriate treatment.¹

Rasim Diler, the editor of this volume, is originally from Turkey. He has been affiliated with the Western Psychiatric Institute in Pittsburgh, Pennsylvania, a hotbed of bipolar disorder research, for several years. He has published a number of articles on the psychopathology of other psychiatric disorders in children, including one on bipolar disorder occurring in Turkish children.

Diler states that “This book aims to take a snapshot of the current status of pediatric bipolar disorder in the world,” and to do so he has recruited published and novice authors from 11 countries or areas (United States, Australia/New Zealand, Brazil/South America, China, India, Israel, Italy, Japan, Spain, Russia, and Turkey). The book begins with the North American perspective, which is meant to outline the issues and provide a review. The authors from each country outside the United States have a chapter in which to describe their country and the practice of child psychiatry, adolescent psychiatry, or both; the authors are also supposed to address the question of how often pediatric bipolar disorder is written about or diagnosed.

A number of the authors (though not always the first author) have, in fact, researched mood or bipolar disorder in children and adolescents. These include Hazell from Australia; Rhode from Brazil; Reddy, Srinath, and Jairam from India; Apter from Israel; Masi and Perugi from Italy; Soutullo from Spain; and Diler from Turkey. Not surprisingly, those chapters have somewhat more specific information to provide about bipolar disorder. Authors from most countries or areas outside the United States (Australia/New Zealand, Brazil, China, India, Israel, Japan, Russia, and Turkey) concluded that the classic adult form of bipolar disorder was rare to absent in prepubertal children. Some described depression and bipolar disorder occurring in adolescents, but that age group is less controversial. What is not clear is how child psychiatrists in other countries label explosive, irritable children, who sometimes have been redefined in the United States as having pediatric bipolar disorder. Even clinicians in the United States agree that the classic form of bipolar disorder is rare in young children. It is the reformulated, chronic, and dysphoric form that is relatively common.

As a child and adolescent psychiatrist, what I found particularly interesting were descriptions of child mental health and adolescent psychiatry training in other countries (Australia, Brazil, China, Japan, Spain, Russia, and Turkey). There are inadequate numbers of child and adolescent psychiatrists in the United States, but they are exceptionally rare elsewhere. If another volume describing child psychiatry practice worldwide exists, I am not aware of it.

Like most edited volumes, some chapters are more coherent and better written than others. The idea of compiling international reflections on early-onset bipolar disorder was a clever one. However, given the primitive state of understanding of this condition in children, I think Pediatric Bipolar Disorder: A Global Perspective is probably a more unique compilation of cross-cultural practice than it is a resource about pediatric bipolar disorder.