Brief reportCharacteristics of the child behavior checklist in adolescents with depression associated with bipolar disorder
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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2016, Journal of Affective DisordersCitation Excerpt :Initially, this profile was proposed as a screening tool for pediatric bipolar disorder (PBD), and was accordingly named the CBCL-PBD profile (Biederman et al., 1995). However, various studies raised doubts about its validity for that purpose (e.g., Diler et al., 2009; Doerfler et al., 2010; Serrano et al., 2013; Southammakosane et al., 2013; Youngstrom et al., 2005), as it was frequently not associated with bipolar disorder but with other conditions such as attention deficit hyperactivity disorder, oppositional defiant disorder, conduct disorder, and personality disorders (Halperin et al., 2011; Holtmann et al., 2008; Kahana et al., 2003; Volk and Todd, 2007). Furthermore, there is some disagreement over the operationalization of childhood bipolar disorder, which may present differently in children and adults (Leibenluft, 2011; Plener et al., 2013; Zepf and Holtmann, 2012).
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2016, Comprehensive PsychiatryCitation Excerpt :Several other groups have suggested that the CBCL-DP could be used for the diagnosis of PBD [8–10]. On the other hand, other investigators failed to find a meaningful association between the CBCL-DP profile and diagnosis of PBD [11–16]. In addition, few studies to date have investigated the discrimination ability of the CBCL between youths with bipolar and depressive disorders [7,14].
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2014, Journal of Affective DisordersCitation Excerpt :These findings thus provide a new orientation to the potential clinical utility of the CBCL-DP. Much of the research to date, however, has been conducted with children from heterogeneous treatment seeking samples, such as those diagnosed with or at risk of developing ADHD or bipolar disorder, two conditions which have regularly been associated with an elevated CBCL-DP score (Biedermann et al., 2009; Faraone et al., 2005; Meyer et al., 2009; Southammakosane et al., 2013; Volk and Todd, 2007; Youngstrom et al., 2005). More studies are needed to determine the applicability to the CBCL-DP as a marker of psychopathological severity in a more homogeneous clinical sample.
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