Brief report
Characteristics of the child behavior checklist in adolescents with depression associated with bipolar disorder

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Abstract

Background

The child behavior checklist-Juvenile bipolar disorder phenotype (CBCL-JBD) has been proposed as a distinct profile specific to children and adolescents who have been diagnosed with bipolar disorder. The objective of this study was to examine whether bipolar disorder youth with depression exhibit the “CBCL-Juvenile bipolar disorder phenotype.”

Methods

Thirty-two adolescents, ages 12–18 years, with a depressive episode associated with bipolar I disorder were recruited, and their primary caregivers completed the CBCL.

Results

Only the internalizing subscale (mean=70.2, SD=9.7) and total score (mean=71.5, SD=8.9) reached clinical significance (>70). Moreover, the CBCL-JBD profile scores of our subjects (204.6, SD=27.5) did not reach clinical significance (>210).

Limitations: Our subjects differed demographically from those in studies that have confirmed the CBCL-Juvenile bipolar disorder phenotype with regards to sex, age and ADHD comorbidity, thus limiting the interpretability of our comparisons with other studies. Furthermore, our investigation involved a small sample size and did not include a control group, which should be addressed in future studies.

Conclusions

The results of our study suggest that the CBCL-JBD profile is not characteristic of depressed youth with bipolar disorder. Better assessment tools for making an accurate and efficient diagnosis of bipolar disorder are needed so that appropriate treatment can be implemented and significant morbidity and mortality are minimized.

Introduction

Bipolar disorder (BD) is a common and recurrent condition, affecting familial, social and educational functioning. Indeed, according to the results of the National Comorbidity Survey-Adolescent Supplement (NCS-A), the lifetime prevalence of bipolar I and II disorders in adolescents is 2.9% (Merikangas et al., 2010). Despite the fact that youth with juvenile bipolar disorder (JBD) experience depression more frequently than mania and that depressive symptoms are often part of initial presentation, the emphasis in the literature has largely been on manic or mixed mood states (Chang, 2009). Additionally, depression associated with BD is often associated with significant morbidity and mortality, including risk of suicide. However, recognizing depressive symptoms that are part of BD as opposed to unipolar depression can be difficult, especially upon initial presentation. The importance of discerning between the two cannot be overstated, though, given the potential risk of manic activation in individuals with bipolar depression who are prescribed an antidepressant (Goldsmith et al., 2011).

Several rating instruments have been validated and used as diagnostic and symptom severity assessments in JBD. The child behavior checklist (CBCL) is a well-studied standardized instrument that assesses the behavioral problems and social competencies of children ages 4 to 18 years, as reported by their caregivers (Achenbach, 1991a, Achenbach et al., 1991b, American Psychiatric Association, 2000b). Biederman et al., 1995, Biederman et al., 1996a, Faraone et al., 2005b) found that children and adolescents who had been diagnosed with BD had a distinct profile on the CBCL; the “CBCL-JBD phenotype.” These findings have been replicated by other investigators (Giles et al., 2007, Hazell et al., 1999, Carlson and Kelly, 1998). Results of a meta-analysis showed that the CBCL-JBD profile can differentiate between children and adolescents with BD and those with ADHD, suggesting discriminant validity of the measure (Mick et al., 2003). The CBCL-JBD phenotype was defined by a profile of T-scores above 70 on the Anxious/Depressed, Aggression, and Attention Problems subscales (Faraone et al., 2005b, Mick et al., 2003, Biederman et al., 2009). A sum of 210 on these subscales has also been shown to maximize the sensitivity, specificity, and positive and negative predictive powers when predicting a current diagnosis of bipolar disorder in children with ADHD (Biederman et al., 2009). None of the CBCL studies looked specifically at youth with bipolar disorder in a current depressed episode; rather subjects from aforementioned studies were either in a current manic state or current mood state was not specified.

Other literature suggests that the CBCL can predict, to varying degrees, depressive disorders. For example, Biederman et al., 1996a, Biederman et al., 2005a, Faraone et al., 2005b, in two separate studies, found the Anxious/Depressed subscale to correlate well with unipolar major depression. Similarly, Eimecke and colleagues (2011) demonstrated low to medium predictive power of this subscale in both unipolar depressive disorder and other disorders with depressive symptomatology, including bipolar disorder.

Although the CBCL has been extensively studied in bipolar youth during manic or mixed episode and in youth with unipolar depression, there is a paucity of data on the CBCL profile of youth with depression associated with bipolar disorder. The aim of this study was to evaluate the CBCL profile of unmedicated adolescents with depression associated with bipolar disorder; we hypothesize that the CBCL profile of our subjects will fit the CBCL-JBD profile, given its purported utility in characterizing youth with BD.

Section snippets

Methods

This study was approved by the University of Cincinnati, the Cincinnati Children's Hospital Medical Center, and the Stanford University Institutional Review Boards. All subjects provided written assent and legal guardians provided written informed consent prior to study participation. Thirty-two adolescents between the ages of 12–18 years who were diagnosed with bipolar I disorder, current episode depressed, were recruited from referrals to the Division of Bipolar Disorder Research at the

Results

Adolescents with bipolar depression showed significantly elevated scores above the accepted norms in most of the CBCL subscales. However, a mean score of >70, indicative of clinical significance, was only evident in the internalizing subscale (mean=70.2, SD=9.7) and the total score (mean=71.5, SD=8.9). The Anxious/Depressed score was elevated (mean=68.9, SD=9.9) but did not reach the cutoff score for clinical significance. Likewise, the CBCL-JBD phenotype score was elevated (mean=204.6,

Discussion

Although the CBCL has been used extensively in youth with a wide variety of psychopathology, including JBD, to our knowledge, this is the first study to specifically examine its utilization in youth with a depressive episode associated with bipolar I disorder. A majority of prior studies focused on the diagnostic utility of the CBCL in bipolar youth with a manic or mixed mood state or who were euthymic. Despite some controversies about the sensitivity and specificity of its use in this

Conflict of interest

This study was partially supported by a grant from AstraZeneca Pharmaceuticals. Additionally, the project described was supported by the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant 8 UL1 TR000077-04. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Within the three years of the start of this study, Dr. Adler has received

Acknowledgments

The authors acknowledge the assistance of the inpatient staff from Cincinnati Children's Hospital Medical Center and partial support by a grant from AstraZeneca Pharmaceuticals.

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