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Historical Perspectives

In the 4th and 5th centuries B.C.E., Hippocrates argued that mental illnesses had biological origins, denying the popular custom of attributing them to supernatural or magical sources. He described “melancholia” as a manifestation of a brain dysfunction, and agreed with the then contemporary humoral theory, which stated that humans must have equilibrium of the four humors – blood, black bile, yellow bile, and phlegm – to have even temperaments. Excessive black bile was considered to be the cause of melancholia; excessive yellow bile was associated with mania. He recommended proper diet, drink and abstinence from sexual activity as cures.

Plato believed that the mind was the cause of madness. He saw mental illness as being the result of “a person's ignorance of a psyche (the force that kept the human being alive), which leads to the self-deception” (Mora, 1985). It was not until later in the 2nd century C.E. that Aretaeus of Cappadocia hypothesized that mania was an end-stage process of melancholia; he described “cyclothymia” as a type of mental disease that alternated between periods of mania and of depression. (Goodwin and Jamison, 1990).

In some Arabic countries during the Middle Ages, many asylums were opened to care for the mentally ill. Muslim ideology was that “the insane person is loved and particularly chosen by God to tell the truth….They were frequently worshipped as saints” (Mora, 1985). In Europe at the same time, however, it was an entirely different story. Religious fervor perpetuated the notion that mental illness was a divine punishment for a (known or unknown) misdeed. As time went on and “witch hunts” became increasingly common, the mentally ill (particularly women) were progressively more persecuted for witchcraft or demonic possession, and usually killed. This persisted well into the 17th century, though in 1602 Swiss doctor Felix Platter published Praxix Medica, the first medical textbook to deal with psychiatry. It also contained classifications of mental diseases, which Platter hypothesized to have “organic humoral causation: however, this view did not necessarily rule out the devil as an etiological factor, at least in some cases of possessed female patients.” (Mora, 1985).

After the scientific revolution of the 18th century, the 19th century laid the groundwork for modern views of bipolar disorder. Falret and Baillarger suggested (independent of each other) that mania and depression were part of the same disease. Subcategories of bipolar disorder were also identified: Mendal (1881) described “hypomania” as “that form of mania that typically shows itself only in the mild stages abortively, so to speak” (quoted in Goodwin and Jamison, 1990), and a year later Kahlbaum re-described cyclothymia as episodes of both mania and depression that did not end in dementia. Despite this research, however, popular opinion was still that mania and melancholia were separate units.

Also in the 19th century, psychiatrist Emil Kraepelin began to group diseases together “based on classification of common patterns of symptoms, rather than by simple similarity of major symptoms in the manner of his predecessors.” (Wikipedia, 2005). To put it another way, he said that symptoms of one illness may also sometimes be found in another, and that it is not any one symptom but a pattern of symptoms that distinguishes one disease from another. He called his view “clinical,” as opposed to the “symptomatic” traditional view (Wikipedia, 2005).

Kraepelin was also the first to separate bipolar disorder from what he called “dementia praecox,” which we now know as schizophrenia. He believed that schizophrenia had a “deteriorating course” (Wikipedia, 2005) in which mental function continuously declines, and bipolar disorder (which he termed “manic depression,” which is now seen as comprising a variety of mood disorders, including bipolar disorder) patients experienced the illness in severe episodes followed by symptom-free intervals. Later, in 1924, Eugen Bleuler suggested that manic depression and dementia praecox were on a continuum or spectrum, and that a person could be at different points on that spectrum at different times. He also extended Kraepelin's category of manic depression into subcategories that would lead to the future classification of subtypes within bipolar disorder.

Leonhard (1950)'s observations led him to use the term “bipolar” to describe patients with a both a history of mania and a higher incidence of mania in their families than patients (whom he called “monopolar” or “unipolar”) who only had experienced depression. This distinction, however, was not introduced into the Diagnostic and Statistical Manual of Mental Disorders (DSM) until its third edition in 1980.

As of 1976, bipolar disorder has been further divided into two subtypes: Bipolar I and Bipolar II. Bipolar I patients are usually diagnosed with acute enough mania that they may display psychosis during manic episodes, and often require treatment. Bipolar II patients have episodes of hypomania (see below), in which they exhibit behaviors that are different than “normal” but do not usually require hospitalization. As of 2003, the World Health Organization now has twelve subtypes and sub-subtypes under “bipolar affective disorder” in its International Classification of Diseases (ICD)-X (2003 Edition).

Racial/Ethnic & Socioeconomic Influences on Identification, Treatment, Outcome

Strakowski and colleagues (2003) report that bipolar disorder seems to have similar prevalence rates across racial and ethnic groups and geographically around the world (Strakowski et al, 2003). However, in the , bipolar disorder is often underdiagnosed in minority patients relative to Caucasian patients. African American patients are significantly more likely to be diagnosed with schizophrenia, and the researchers note that clinicians tend to focus less on the affective (mood) symptoms in African American patients, and more on the psychotic symptoms. Misdiagnoses like these can lead to dangerous outcomes, such as incorrect medication or insufficient psychotherapy.

In an earlier study, Strakowski and different colleagues (1993) found that a patient's ethnicity influences clinical decision-making in psychiatry: “African American patients are more likely to be treated with �as needed' medication and to be placed in seclusion or restraints, and they receive more antipsychotic medication and at higher doses than similar Caucasian patients.” (Strakowski et al, 1993). They studied the hospital records of all adolescents with a discharge diagnosis of bipolar disorder at Cincinnati Children's HospitalMedicalCenter'sAdolescent Psychiatry Unit between July 1995 and June 1998 for demographic/clinical variables. 14 of the patients were African American, 60 were Caucasian, and all of the psychiatrists treating the adolescents were Caucasian. Although the psychotic symptoms (in this case hallucinations, delusions, or thought disorder) reported by the two groups were roughly equal, the African American patients were nearly twice as likely as the Caucasian patients (86% compared to 45%, respectively) to receive treatment with an antipsychotic medication. While Strakowski and his colleagues admit that many unknown factors may contribute to the causes behind their findings, they still maintain that further research is needed regardless, as the inconsistency in treatment is so significant.

In 2001, the Department of Health and Human Services released a report on the Surgeon General's Conference on Children's Mental Health. In it, the Surgeon General called for the elimination of racial/ethnic and socioeconomic disparities in access to mental healthcare. The action plan included such suggestions as:

Co-locate mental health services with other key systems (e.g., education, primary care, welfare, juvenile justice, substance abuse treatment) to improve access, especially in remote or rural communities; Strengthen the resource capacity of schools to serve as a key link to a comprehensive, seamless system of school- and community-based identification, assessment and treatment services, to meet the needs of youth and their families where they are; Encourage the development and integration of alternative, testable approaches to engage families in prevention and intervention strategies (e.g., pastoral counseling); Develop policies for uninsured children across diverse populations and geographic areas to address the problem of disparities in mental health access; Increase research on diagnosis, prevention, treatment, and service delivery to address disparities, especially among different racial, ethnic, gender, sexual orientation, and socioeconomic groups. (2001).

At one of the conference panels, Dr. David Takeuchi cited a recent study assessing health outcomes for all 50 states, noting that there was a strong correlation between racial composition and health: the greater the minority composition, the poorer the health profiles. Another variable linked to the health outcomes was how willing the state was to fund social welfare programs. Later in the same panel, Margarita Alegr�a of the University of Puerto Rico argued that merely providing managed care/Medicaid eligibility may not be enough, and that there must be increased provider availability and provider payment incentives to fund children in economically depressed communities, schools, juvenile justice systems, and welfare agencies.

Symptoms and Effects of Bipolar Disorder

A lot more research has been done into the respective subtypes over the last ten years. Bipolar II is characterized by the fact that most patients do not experience the traditional version of “mania,” but rather periods of severe depression with separate hypomanic phases. Symptoms of hypomania include “mood much better than normal, rapid speech, little need for sleep, racing thoughts, trouble concentrating, continuous high energy, overconfidence” (Phelps, 2005). If the depression is only mild, the ancient term “cyclothymia” is still used. Bipolar I, on the other hand, is characterized by the aforementioned mania and severe depression, sometimes “mixed,” in which aspects of both appear at the same time. In additions to the symptoms found in hypomania, mania includes delusion (”often grandiose, but including paranoid” (Phelps, 2005)).

This list of clinical descriptions does not, however, thoroughly portray the experiences of a person with bipolar disorder. One professional in the psychiatric field who has bipolar disorder herself, explains:

The clinical reality of manic-depressive illness is far more lethal and infinitely more complex than the current psychiatric nomenclature, bipolar disorder, would suggest. Cycles of fluctuating moods and energy levels serve as a background to constantly changing thoughts, behaviors, and feelings. The illness encompasses the extremes of human experience. Thinking can range from florid psychosis, or “madness,” to patterns of unusually clear, fast and creative associations, to retardation so profound that no meaningful mental activity can occur. Behavior can be frenzied, expansive, bizarre, and seductive, or it can be seclusive, sluggish, and dangerously suicidal. Moods may swing erratically between euphoria and despair or irritability and desperation. The rapid oscillations and combinations of such extremes result in an intricately textured clinical picture.” (Kay Jamison, Ph.D., 1996)

Bipolar disorder also affects families. Despite much research, there are no certain genes or chromosomes that have been found to cause it. Most researchers have deemed it a “multi-gene condition” to account for the many variations, but it is now unquestionably known to be genetically based. The reported odds of a child having bipolar disorder have historically been “roughly 20% chance if one parent has it, 50-70% chance if both do” (Phelps, 2005); there has not been separate work done on Bipolar I and II families, but so far the prognoses appear to be similar. Duffy and colleagues (2000) caution that the percentages can change depending on the number of affected relatives: if there are a lot, the risk to the children may be higher than 20%, but if there aren't very many, the risk could be lower.

Treatments

Treatment can be a complicated affair. First, it is important to note that many researchers and doctors caution against using antidepressants to treat bipolar disorder. While they may help the depression part, they can also cause “rapid cycling,” which technically means more than four mood episodes per year, but can occur as often as every day or multiple times per day. In addition, they can influence hypomanic or manic symptoms, and can induce the previously mentioned mixed states.

The primary treatment approach is the use of mood stabilizers such as lithium and valproate (Depakote, an anti-convulsive for those who have rapid cycling between mania and depression), and more recently lamotrigine, olanzapine (Zyprexa), and carbamazepine (another anti-convulsant that is often used to treat rage attacks). There are some negative side effects to all of the medications, the most dramatic being “tremors” and “mental dulling” associated with lithium (Phelps, 2005).

Another treatment that has been shown to be extremely effective when combined with medication is comprised of certain forms of psychotherapy. Four therapies in particular have been named as consistently helpful (Spearing, 2001). Psychoeducation (Colom, Vieta, and colleagues) teaches about the illness, its treatment, and how to recognize signs of a relapse so that early intervention may be sought. Cognitive behavioral therapy (Lam and colleagues) teaches people to change negative/inappropriate thought patterns and behaviors. Interpersonal and social rhythm therapies (Frank and colleagues) helps improve interpersonal relationships and regularize daily routines and sleep schedules – two things which may help stave off manic episodes. Finally, family-focused therapy (Miklowitz and colleagues) helps reduce stress within families that may either add to or be a result of the patient's symptoms. All four of these differ greatly from the traditional Freudian psychoanalytic psychotherapy, and have been specifically developed for the needs of patients with bipolar disorder. At a base level, all of the therapies emphasize: “identifying signs of relapse and making plans for early detection and response; using education to increase agreement between doctor, patient, and family about what is being treated and why; emphasis on the need to stay on medications even when well.” (Phelps, 2005).

The Massachusetts General Hospital (MGH) Bipolar Clinic and Research Program offers a “mood chart” to use as “a simple means of generating a graphic representation of your illness over the past month….to systematically bring together important pieces of information such as medication levels, mood state, and major life events to see emerging patterns that otherwise might be difficult to discern.” (MGH Bipolar Clinic and Research Program, 2005). This particular mood chart uses a 0-3 scale to rate daily moods in three main categories: depressed, elevated, and no symptoms. Each category contains space to record whether the mood affected the person's ability to work. There are also spaces for recording hours slept during the night, anxiety, irritability, treatments, and psychotic symptoms such as “strange ideas” and “hallucinations.”

MGH also offers a “treatment contract,” or a “document that you write while you are feeling well to plan for the times when you do not feel as well. It is written so you, your family, friends, and doctors can recognize your symptoms of illness and can comply with your wishes for treatment.” (MGH Bipolar Clinic and Research Program, 2005). For a sample treatment contract, see attached.

Pediatric Bipolar Disorder

Research shows that symptoms of bipolar disorder can be present since infancy or early childhood, or can emerge in adolescence or adulthood. The Child and Adolescent Bipolar Foundation (CABF) reports that it is suspected that some ADHD (attention deficit disorder with hyperactivity) diagnoses may actually be cases of early-onset bipolar disorder. CABF also notes that because depression in children and teens can be chronic and relapsing, some proportion of the 3.4 million children and adolescents with depression may be experiencing early-onset bipolar disorder as well, but have just not yet reached the manic phase.

The symptoms can look different in children than they do in adults. Children often have a much more rapid cycling, decreasing the amount of symptom-free time in between episodes. Diagnosis is made at all ages using the DSM-IV criteria, though it is sometimes difficult to apply them to infants and young children. Some listed behaviors include: “extreme sadness or lack of interest in play; explosive, lengthy, and often destructive rages; separation anxiety; defiance of authority; bed wetting and night terrors; excessive involvement in multiple projects and activities; dare-devil behavior (such as jumping out of moving cars or off roofs); inappropriate or precocious sexual behavior; grandiose belief in own abilities that defy the laws of logic (ability to fly, for example)” (CABF, 2005).

For some, a traumatic event may trigger the first episode (either of mania or of depression). In girls, the beginning of puberty may trigger an episode, and symptoms sometimes vary throughout the monthly cycle. Once the episodes begin, they tend to recur and get worse if the child does not receive treatment. Studies have shown that there is, on average, a ten-year gap between the onset of symptoms and the beginning of treatment. Untreated, the prognosis is not good. Many teens with untreated bipolar disorder abuse drugs and alcohol. Isolation from peers, disinterest in former hobbies and activities, drops in grades, and thoughts of suicide and death are all common side effects.

Methods for treating pediatric bipolar disorder are similar to those for treating adults: mood stabilizers and often therapy (usually several months later, after the mood stabilizers have taken effect). There are only a few medications that are regularly prescribed for children, such as Depakote, Carbamazepine, sometimes lithium, and more recently marketed anti-convulsants Lamotrigine (Lamictal, not used in children under six years) and Tiagabine (Gabitril). For more extreme manic episodes, doctors may prescribe antipsychotic medications, and anti-anxiety medications like Xanax and Klonopin are sometimes used in conjunction with mood stabilizers and/or antipsychotics.

In terms of therapies, the two most commonly used are cognitive behavioral therapy and interpersonal therapy. Families may participate in multi-family support groups, and parents sometimes engage in techniques that the CABF calls “therapeutic parenting.” These include: “practicing and teaching their child relaxation techniques; using firm restraint holds to control rages; reducing stress in the home and becoming an advocate for stress reduction and other accommodations at school; using music and sound, lighting, water, and massage to assist the child with waking, falling asleep, and relaxation; helping the child anticipate and avoid, or prepare for stressful situations by developing coping strategies beforehand.” (CABF, 2005).

Educational Policies and Implications

Section 504 of the Rehabilitation Act of 1973, “Nondiscrimination Under Federal Grants and Programs,” protects those diagnoses with psychological disorders if their condition fundamentally limits a major life activity, one of which is learning. Students who meet this requirement are entitled to receive whatever accommodations allow them to have an equal chance to participate in all aspects of school life. In addition, Title III of the Americans with Disabilities Act says that any institutions that receive federal funding must provide accommodations for testing as well, such as extended time to take the exam, extra breaks, a testing environment without distractions, or, in some extreme cases, testing via a different format.

These two policies are predominantly applicable to those who decide that a mainstream classroom is the ideal place for a particular child with bipolar disorder. The Juvenile Bipolar Research Foundation, saying that the accommodations mandated by Section 504 may be inadequate for those with more extensive needs. They suggest some alternatives which fall under the Individuals with Disabilities Education Act (IDEA) of 1997, such as more support outside the classroom, time spent in a resource room and/or with an aide, or a later-starting school day. Many of these services are not usually available unless the child has an Individualized Education Plan (IEP), so the Foundation recommends that the process to obtain one begins as early as possible, and that Section 504 accommodations may be used as an emergency measure, but they should not be relied on for consistent support in schools. Children with bipolar disorder usually fall under two of the 13 IDEA categories that entitle students to services and accommodations: “seriously emotionally disturbed” (SED) (also called “emotionally disordered”/ED and “behaviorally disturbed”/BD in some states), and “other health impaired” (OHI).

Bipolar disorder and its medicinal treatments may affect many aspects of a child's academic life, including attendance, concentration, impulse control, alertness, sensitivity to noise and light, and ability to cope with stress. The child's individual needs will depend on many variables such as the duration and frequency of his or her episodes. Transitional times like beginning at a new school or with a new teacher or returning to school after a vacation often cause an increase in the intensity of symptoms. In addition, medicines may cause side effects that interfere with the child's participation in school: sleepiness or agitation, difficulty concentrating, and increased thirst. Weight gain and the tendency to become quickly dehydrated hinder involvement in sports, recess, and gym.

BostonUniversity's Center for Psychiatric Rehabilitation (CPR) adapted some of Mancuso's suggested accommodations for workers with psychiatric disabilities (Mancuso, 1990) to apply to accommodations for students with bipolar disorder. For instance, if a child is sensitive to noise or light, the CPR suggests that he or she asks the teacher to be allowed to do independent work in a quiet or more dimly lit study area. For difficulty concentrating or short-term memory problems, they suggest asking to break larger projects into smaller tasks, asking for assignments to be given one by one or in writing, and asking permission to take multiple short breaks while completing an assignment. If attendance becomes an issue, possibilities include the parents or the school requesting a tutor, and/or the teacher sending home/to the hospital copies of the weekly lessons and assignments so that the child is as caught up as possible when they return to school. Warner and colleagues (2003) add that the school should designate a “safe place or person” inside the school where the child can go in times of severe stress or irritability. In addition, they suggest that the child's teachers use a “flexible approach” that can vary depending on the student's mood and presentation, and (much like MGH's treatment contract) teach the student how and what to ask for during more difficult times when they may feel less in control of themselves.

As a final note, it must be mentioned that in the most extreme cases, in which children are a danger to themselves and/or others, or in which they need more constant and careful observation of their illness than a mainstream school can provide, there is the option of residential treatment centers. These are medical facilities that have psychiatrists and nurses on staff, administer and monitor medications, and provide therapy and schooling (following the student's IEP, as is required by law). One drawback to these facilities is the potential isolation of the student from the outside world, including his/her family. Another is the cost – anywhere from $50,000 to over $125,000 per year. A school district may pay some or most of the fee, but usually only after a due process hearing has taken place.

Conclusion

Bipolar disorder is an increasingly prevalent mental illness that requires constant management and a great deal of personal struggle. It deserves to be taken as seriously and offered as many accommodations as a more visible physical disability, and it is imperative that accessible, affordable, effective treatment be made available to all those who suffer from it, regardless of race, ethnicity, language, or socio-economic status.

BIBLIOGRAPHY

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Child & Adolescent Bipolar Foundation (CABF). Philadelphia, PA. http://www.bpkids.org.

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Warner, B., Parr, J., Alexander, T., Brey, L. (2003). “Early Onset Bipolar Disorder in Children and Adolescents: A Brief Overview”. National Assembly of School-Based Health Care: University of Maryland at College Park.

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