Cyclothymic temperament as a prospective predictor of bipolarity and suicidality in children and adolescents with major depressive disorder

Introduction: Although several recent studies suggest that bipolar disorder most commonly begins during childhood or adolescence, the illness still remains under-recognized and under-diagnosed in this age group. As part of the French Bipolar network and in line with the hypothesis that juvenile depression is pre-bipolar (Akiskal, 1993), we evaluated the rate of onset of bipolar disorders in a naturalistic 2-year prospective study of consecutive, clinically depressed children and adolescents, and to test whether the cyclothymic temperament underlies such onset. Methods: Complete information was obtained from both parents and patients in 80 of 109 depressed children and adolescents assessed with Kiddie-SADS semi-structured interview, according to DSM IV criteria. They were also assessed with a new questionnaire on cyclothymic-hypersensitive temperament (CHT) from the TEMPS-A cyclothymic scale adapted for children (provided in Appendix A), and other assessment tools including the Child Depression Inventory (CDI), Young Mania Rating Scale, Clinical Global Assessment Scale (CGAS), and Overt Aggressive Scale (OAS). Results: Of the 80 subjects, 35 (43%) could be diagnosed as bipolar at the end of the prospective follow-up. This outcome was significantly more common in those with cyclothymic temperament measured at baseline. Most of these patients were suffering from a special form of bipolar disorder, characterized by rapid mood shifts with associated conduct disorders (CD), aggressiveness, psychotic symptoms and suicidality. Limitation: The primary investigator, who took care of the patients clinically, was not blind to the clinical and psychometric data collected. Since all information was collected in a systematic fashion, the likelihood of biasing the results was minimal. Conclusion: We submit that the CHT in depressed children and adolescents heralds bipolar transformation. Unlike hypomanic or manic symptoms, which are often difficult to establish in young patients examined in cross-section or by history, cyclothymic traits are detectable in childhood. Our data underscore the need for greater effort to standardize the diagnosis and treatment of pre-bipolar depressions in juvenile patients.