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Phenomenology, socio-demographic factors and outcome
upon discharge of manic and mixed episodes in
hospitalized adolescents
Julie Brunelle, Angèle Consoli, Marie-Laure Tanguy, Christophe Huynh,
Didier Perisse, Emmanuelle Deniau, Jean-Marc Guilé, Priscille Gérardin,
David Cohen
To cite this version:
Julie Brunelle, Angèle Consoli, Marie-Laure Tanguy, Christophe Huynh, Didier Perisse, et al.. Phe-
nomenology, socio-demographic factors and outcome upon discharge of manic and mixed episodes
in hospitalized adolescents. European Child and Adolescent Psychiatry, Springer Verlag (Germany),
2009, 18 (3), pp.185-193. �10.1007/s00787-008-0715-7�. �hal-00486568�
Julie Brunelle
Ange
`
le Consoli
Marie-Laure Tanguy
Christophe Huynh
Didier Pe
´
risse
Emmanuelle Deniau
Jean-Marc Guile
´
Priscille Ge
´
rardin
David Cohen
Phenomenology, socio-demographic factors
and outcome upon discharge of manic
and mixed episodes in hospitalized
adolescents
A chart review
Received: 12 February 2008
Accepted: 6 July 2008
Published online: 6 January 2009
J. Brunelle Æ A. Consoli Æ D. Pe
´
risse
E. Deniau Æ Prof. D. Cohen (&)
Service de Psychiatrie de l’Enfant
et de l’Adolescent
Groupe Hospitalier Pitie
´
-Salpe
´
trie
`
re
47 Bd de l’Ho
ˆ
pital
75651 PARIS cedex 13, France
Tel.: +33-1-42-16-23-51
Fax: +33-1-42-16-23-31
E-Mail: david.cohen@psl.ap-hop-paris.fr
J. Brunelle Æ A. Consoli Æ J.-M. Guile
´
D. Cohen
Laboratoire ‘‘Psychologie et Neurosciences
Cognitives’’, CNRS FRE 2987
Paris, France
M.-L. Tanguy
Department of Biostatistics, AP-HP,
Ho
ˆ
pital Pitie
´
-Salpe
ˆ
trie
`
re
Universite
´
Pierre et Marie Curie
Paris, France
C. Huynh Æ J.-M. Guile
´
Department of Child and Adolescent
Psychiatry, Universite
´
de Montreal
Montreal, Canada
P. Ge
´
rardin
Department of Child and Adolescent
Psychiatry, Ho
ˆ
pital C.Nicolle
Rouen, France
j Abstract Background The exis-
tence of bipolar disorder type I
(BD-I) during adolescence is now
clearly established whereas there
are still some controversies on
BD-II and BD-NOS diagnosis,
mainly in Europe (O’Dowd in Br
Med J 29, 2006). Little is known on
the phenomenology and potential
short-term prognosis factors of
bipolar episodes in this age pop-
ulation. In particular, very few
studies examine this issue on
inpatients in the European context
of free access to care.
Objective
To describe the phenomenology of
acute manic and mixed episodes
in hospitalized adolescents and to
analyse potential predictive factors
associated with clinical improve-
ment at discharge and length of
hospitalization.
Methods A total
of 80 subjects, aged 12–20 years,
consecutively hospitalized for a
manic or mixed episode. Socio-
demographic and clinical data
were extracted by reviewing pa-
tients’ charts. We used a multi-
variate analysis to evaluate short-
term outcome predictors.
Results
The sample was characterized by
severe impairment, high rates of
psychotic features (N = 50,
62.5%), a long duration of stay
(mean 80.4 days), and an overall
good improvement (86% very
much or much improved). Thirty-
three (41.3 %) patients had a
history of depressive episodes, 13
(16.3%) had manic or brief psy-
chotic episodes but only 3 (3.7%)
had a history of attention deficit/
hyperactivity disorders. More
manic episodes than mixed epi-
sodes were identified in subjects
with mental retardation (MR) and
in subjects from migrant and/or
low socio-economic families.
Overall severity and female gender
predicted better improvement in
GAF scores. Poor insight and the
existence of psychotic features
predicted longer duration of stay.
Conclusion These results suggest
that severe manic and mixed epi-
sodes in adolescents with BD-I
need prolonged inpatient care to
improve and that socio-cultural
factors and MR should be exam-
ined more closely in youth with
BD.
j
Key words bipolar disorder
type I – acute episode –
adolescent – prognosis –
socio-cultural factors
BRIEF REPORT
Eur Child Adolesc Psychiatry (2009)
18:185–193 DOI 10.1007/s00787-008-0715-7
ECAP 715
Introduction
Interest in juvenile mania is recent despite the semi-
nal description in Kraepelin’s monograph [37] and
several retrospective studies revealing that 20–60% of
adults with bipolar disorder (BD) had their first
symptoms before the age of 20 years [30, 41, 48].
Despite the fact that diagnosing BD during adoles-
cence remains difficult [7, 8] and that controversies
still remain concerning the existence of BD-NOS and
BD-II in this age population, mainly in Europe [44],
typical BD-I in teens is no longer controversial [11].
In adolescents, BD is a frequent diagnosis but BD-I is
much more rare with lifetime prevalence rates of 1
and 0.1%, respectively [39, 34].
As compared to adult-onset BD, the phenomenol-
ogy of acute manic episodes in adolescents can be
summarized as follows: (1) more mixed episodes than
purely manic ones, with frequent aggressive behaviors
and irritability [25, 43, 46]; (2) the presence of psy-
chotic features in 30–50% of the cases [9]; (3) high
rates of comorbidities including ADHD, substance
abuse, conduct and anxiety disorders [3, 14, 24, 49]
and (4) a rapid cycling profile more often observed [5,
38]. However, regarding rates and severity of psy-
chotic features, inconsistent results are found in the
literature. Patel et al. [46], in a comparative study of
clinical characteristics of early-onset (<18 years)
versus typical-onset (20–30 years) BD, showed that
typical-onset patients were rated with more severe
psychotic features than early-onset patients whereas
other authors found the opposite [10, 20]. In the
largest study published so far that included 438 chil-
dren and adolescent with bipolar spectrum disorder
(14.8% inpatients only), the prevalence rate of psy-
chotic symptoms and mixed polarity was 38 and 34%,
respectively [2].
Several prospective studies have been conducted
on the course of illness and long-term prognosis of a
manic episode in adolescents but few exhibit results
on the determinants of short-term outcome. To
summarize, mixed polarity, low socioeconomic status
(SES), young age at onset, previous affective episode,
psychosis and female sex were associated at least in
one study with a poorer outcome [5, 18, 27, 29, 52].
Furthermore, in the US, inpatient treatment tends to
be shorter and shorter (median lenght of stay for BD
in 2000 is 5.6 days) due to economic pressures [12],
which leads to a bias in short-term prognosis studies.
As underlined by Strober et al. [53], observational
data are sparse in the literature on BD in youths de-
spite their great importance for assessment of prog-
nosis and prospective long-term studies. In
prospective studies on adults with BD, longer dura-
tion of the intake episode, depressive or mixed
polarity of the intake episode and substance use
comorbidity have been identified as factors associated
with greater morbidity [31, 32].
The current report is the first step of a follow-up
study on youth hospitalized for an acute manic or
mixed episode during a 10-year period (1993–2003) in
a University hospital that serves a population of 8–
10 million people. It aims to describe the phenome-
nology of acute manic and mixed episodes in this
sample and to look for potential outcome predictors
of these BP-I adolescents inpatients. To our knowl-
edge, this is one of the first European reports on this
issue on a sample of inpatients. Given the tendency of
using BD as a broad spectrum including BD types I
and II, paediatric BD and some borderline subjects [1]
as well as the tendency to exclude patients with
mental retardation (MR) from clinical studies, we
aimed to focus on a sample of patients admitted for
an acute manic or mixed episode, with severe im-
pairement leading to hospitalization with no exclu-
sion criteria. We assume that this sample would be
representative of one end of the BD spectrum, to
avoid confusion in the definition of bipolarity in
youths.
Using a retrospective design, this report describes
the sociodemographic and clinical data of the sample
and the factors associated with short-term prognosis,
defined as clinical improvement and length of hos-
pitalization. We hypothesized that clinical severity,
presence of psychotic features, low SES and/or MR
would be associated with prognosis at discharge.
Methods
j Subjects
By reviewing patient charts and staff reports, we
systematically looked for all children and adolescents
consecutively hospitalized for an acute manic or
mixed episode between January 1993 and December
2003 at the Pitie
´
-Salpe
ˆ
trie
`
re Hospital, a University
teaching hospital in Paris area that realizes 30–50% of
all inpatients stay in child and adolescent psychiatry.
During the study period, out of 4,165 inpatients, 120
subjects were hospitalized with a discharge diagnosis
of BD, schizoaffective or schizophreniform disorder,
brief psychotic episode, manic episode, mixed episode
and BD NOS. Two experienced child and adolescent
psychiatrists of the department who had been the
treating clinicians for some of the subjects but not all,
reviewed the charts and selected all cases (N = 80)
meeting a DSM IV discharge diagnosis of BD-1
(manic or mixed episode). No a priori exclusion cri-
teria such as MR were used. For descriptive purposes,
186 European Child and Adolescent Psychiatry (2009) Vol. 18, No. 3
Steinkopff Verlag 2009
the number of subjects by year of hospitalization is
indicated in Fig. 1. As previously mentioned, this
report was a preliminary study of a follow up one.
Thirty-two subjects (40%) of the current sample could
have been traced and evaluated at this point of the
study. They were administered the diagnostic inter-
view for genetic studies (DIGS) [19]. The DIGS con-
firmed that the index episode diagnosis was manic or
mixed in all of them. The study was conducted
according to the hospital ethics committee regulation.
j Procedures and variables
For description of the index episode, we restrospec-
tively reviewed charts (clinician and nurse notes)
from the hospitalization period. All information per-
taining to the identity of the subjects was removed.
Selected data included sociodemographic data [gen-
der, age at admission, parental origins, socio-eco-
nomic status (SES)], past personal and family
psychiatric history recorded at intake with a semi
structured interview [55] and provided by the patients
themselves when their clinical state allowed it and/or
their parents (or care persons). Past psychiatric his-
tory was confirmed using the DIGS for the 32 subjects
already evaluated at follow up. Clinical data reviewed
were the type of episode (manic or mixed) and the
type of onset [acute (<10 days) or not], duration of
hospitalization, presence of psychotic features (delu-
sions and/or hallucinations as described in the DSM
IV), the clinical global impression scale-severity of
illness (CGI-S) [15] and the global assessment of
functioning scale (GAF) [21] that are both systemat-
ically scored at admission and discharge. Charts were
also reviewed by the investigator, a third not treating
psychiatrist, with respect to psychiatric symptoms at
intake using the brief psychiatric rating scale (BPRS)
[6], the Young mania rating scale (YMRS) [56], the
Montgomery and Asberg depression rating scale
(MADRS). A confirmatory inter-rater reliability study
was performed on the YMRS, the BPRS and the
MADRS in a sub-sample of ten randomly selected
charts: intraclass correlations were 0.83, 0.64, and
0.45, respectively. Therefore, we considered invalid to
keep MADRS scores in the analysis. Because the cases
were selected for review on the basis of the presence
of a of BD-1 diagnosis, researchers could not be blind
to the diagnosis. Mental retardation was recorded and
defined by global IQ, verbal IQ or performance IQ <
70 (WISC III and WISC IV). When no cognitive
evaluation was done during the stay because of clin-
ical impairment (N = 38), subjects were identified as
having MR according to the follwing definition of the
American Association on Intellectual and Develope-
mental Disabilities: Intellectual disability is a dis-
ability characterized by significant limitation both in
intellectual functioning and in adaptative behavior as
expressed in conceptual, social and practical adaptive
skills. This disability originates before the age of 18
[42]. To assess short-term outcome, we selected two
variables: duration of stay (days) and global clinical
improvement measured by DGAF (GAF at discharge–
GAF at intake). Comorbid diagnoses were also
reviewed but for this issue no systematic clinical
semi-structured interview is used in current practice
in the departement.
j Statistical analysis
For clinical and socio-demographic variables of the
total sample, we used classic descriptive statistics.
Manic and mixed patients were compared using Stu-
dent’s t tests for continuous variables and Chi-square
or Fisher exact tests for categorical variables. Vari-
ables included in the univariate analysis to identify
predictors of longer duration of stay and clinical
improvement (DGAF) were: age, sex, SES, father’s
origin, mother’s origin, polarity of the episode, type of
onset, psychosis, MR, BPRS (global score and each
subscore), YMRS (global score and each subscore),
CGI-severity and GAF score at intake. A stepwise
multivariable linear regression analysis was then used
to identify predictors of outcome upon discharge.
Variables included in the model were univariate
predictors with P value < 0.05. Two-tailed values of
P < 0.05 were considered statistically significant. All
0
2
4
6
8
10
12
1993
N patients
20032001
1999
19971995
Fig. 1 Number of patients per year of hospitalization included during the
study period (1993–2003). The notable decrease in admission of bipolar youths
in 2000 and 2001 is related to the fact that 15 adolescent inpatients beds were
unavailable during these 2 years
J. Brunelle et al. 187
Phenomenology of acute manic and mixed episodes in hospitalized adolescents
analyses were performed with the SAS software ver-
sion 8.2 (SAS Institute, Cary, NC).
Results
j Socio-demographic and clinical characteristics
of the sample
The sample was composed of 45 females and 35 males
with a mean age of 15.7 (±1.9) years (range 12–19).
The socio-demographic and clinical characteristics of
the sample are summarized in Table 1.
We found past psychiatric history in 68 subjects
(85%). In 33 of them (41.3%), depressive episodes
were identified. Two subjects (2.5%) had presented a
previous manic episode and 11 patients (13.7%) had a
previous brief psychotic episode. Three adolescents
(3.7%) had suffered from ADHD during childhood
but it was always associated with concurrent disor-
ders (conduct disorder, substance abuse or depres-
sion).
Previous family psychiatric history was mentioned
in the history interview for 50 subjects (62.5%). Ten
subjects (12.5%) had a family history of BD—seven
(8.75%) at first degree and three (3.7%) at second
degree. Thirty patients (37.5%) reported at least one
member of their family having a depressive disorder
and 10 (12.5%) had at least one member of their
family with a psychotic disorder not specified.
As shown in Table 1, 49 adolescents presented with
a manic episode and 31 with a mixed episode. Thirty
subjects (37.5%) reported an acute onset of the epi-
sode (£10 days). Psychotic features were found in 50
patients (62.5%). Mean IQ was in the low range of
normality [mean IQ = 83.4 (±23.4)] and 17 subjects
(21.3%) had MR. Clinical severity scores, as assessed
on the different scales at admission, confirmed that
the sample was composed of severely impaired pa-
tients representing one end of the BD spectrum. De-
Table 1 Clinical and socio-demographic characteristics of youths hospitalized from 1993 to 2003 for acute manic and mixed episodes in a University Hospital
(N = 80)
Total (N = 80) Manic episode (N = 49) Mixed episode (N = 31)
Socio-demographic characteristics
Sex 45 F, 35 M 27 F, 22 M 18 F, 13 M
Age (mean ± SD) 15.67 ± 1.89 15.65 ± 1.9 15.74 ± 1.87
Socio-economic status: N (%) good and middle 50 (63.3) 26 (53)* 24 (77.4)*
Paternal origin: N (%) migrants
a
34 (44.2) 27 (55)* 10 (32.2)*
Maternal origin N (%) migrants 33 (43.4) 25 (51) 12 (38.7)
Both parents origin: N (%) migrants 38 ( 47.5) 19 (38.8) 9 (29)
Previous psychiatric history
Personal history: N (%) 68 (85) 42 (85.7) 26 (83.9)
Family history: N (%) 50 (62.5) 30 (61.2) 20 (64.5)
Total IQ (mean ± SD)
b
83.4 ± 23.4 78.3 ± 23.3 100.7 ± 21.5
Verbal IQ (mean ± SD)
c
89.9 ± 22.2 87.2 ± 22.3 96.2 ± 20.6
Performance IQ (mean ± SD)
d
83.9 ± 24.8 79.3 ± 25.7 95.2 ± 18.9
Mental retardation: N (%) 17 (21.3) 14 (28.6)* 3 (9.6)*
Clinical characteristics
Acute onset (£10 days): N (%) 30 (37.5) 20 (40.8) 10 (32.2)
Psychotic features: N (%) 50 (62.5) 27 (55) 23 (74.2)
Catatonic features: N (%) 4 (5) 2 (4) 2 (6.4)
Mental retardation: N (%) 17 (21.3) 14 (28.6) 3 (9.6)
Duration of stay, days (mean ± SD) (range) 80.4 ± 50.7 (17–245) 81.3 ± 52.3 (17–245) 77.4 ± 47.5s (18–199)
Scores at admission
GAF (mean ± SD) [range] 23 ± 7.9 [10–40] 23 ± 7.7 [10–40] 22.9 ± 7.7 [10–40]
CGI-S: N (%) severely/extremely ill 61 (76.3) 38 (77.5) 23 (74.2)
BPRS (mean ± SD) 63.3 ± 15.0 62.9 ± 12.8 62.2 ± 14.7
YMRS (mean ± SD) 22.2 ± 6.5 22.2 ± 6 22.1 ± 6
Scores at discharge
GAF (mean ± SD) 64 ± 14.4 64.2 ± 12.7 64.2 ± 12.9
CGI-I: very much improved N (%) 18 (22.4) 12 (24.4) 6 (19.3)
much improved N (%) 51 (63.8) 28 (57) 23 (74)
minimally improved N (%) 11 (13.8) 9 (18.4) 2 (6.5)
IQ intellectual quotient, GAF global assessment of functioning scale, CGI-S clinical global impressions-severity of illness scale, BPRS brief psychiatric rating scale,
YMRS Young Mania rating scale, MADRS montgomery and asberg depression rating scale, CGI-I clinical global impressions-improvement
* P < 0.05
a
Migrants: from all countries but France and DOM-TOM;
b
N = 31;
c
N = 42;
d
N =42
188 European Child and Adolescent Psychiatry (2009) Vol. 18, No. 3
Steinkopff Verlag 2009
