"It's possible for this group of patients to do very well," said Ketter, who examined the medical and treatment histories of college students treated at Stanford's Bipolar Disorders Clinic. "It's important to realize that these students can function well if they get accurate diagnosis and treatment." Researchers on Ketter's team are presenting their findings during two sessions at the annual meeting of the American Psychiatric Association Meeting in New York.
According to the National Alliance for the Mentally Ill, 2.3 million American adults have bipolar disorder, which is marked by episodes of mania and depression that typically begin in adolescence or early adulthood and can last from days to months. Family history is a powerful indicator; Ketter said a member of the general population on average has a 2 percent chance of having bipolar disorder while a person with a family history of the disease has a 20 percent risk.
Misdiagnosis is common because its symptoms - which include mood swings into euphoria or irritability as well as deep depression - resemble those of other disorders, such as unipolar depression or attention-deficit/hyperactivity. Ketter noted that the average time between a patient's onset of symptoms and accurate diagnosis is 10 years. Yet early and accurate diagnosis is important in preventing disease-related episodes, which potentially lead to illness progression.
"It's much easier to treat patients who have had fewer than three episodes; after that it gets incrementally more difficult to treat," said Ketter. "If we don't let episodes occur, patients can do exceedingly well."
Research has been done on adolescent and adult bipolar disorder, but few studies have focused specifically on the college-age population. Ketter said he believes adults shouldn't be considered a monolithic group; unlike middle-aged and older adults, patients in early adulthood haven't had decades of episodes and may be easier to treat.
His team conducted a review to assess the illness severity and prognosis of this often overlooked group. They examined the cases of 42 bipolar college students, each of whom was enrolled in the Systematic Treatment Enhancement Program for Bipolar Disorder, the largest treatment study ever conducted for the disease. The average age of the patients was just under 22 and the average age of illness onset was just over 16. Prior hospitalizations (64 percent) and anxiety disorders (63 percent) were common; in addition, 43 percent had a history of heavy marijuana use, 37 percent had a history of alcohol abuse and 26 percent had attempted suicide.
The research team found that the patients' average scores on the Clinical Global Impression, or CGI scale (a marker of a person's mental illness) and on the Global Assessment of Function scale (which rates overall psychological, social and occupational functioning) improved significantly during treatment. It also found the percentage of patients with "syndromal episodes," which are clinically significant episodes of depression or mood elevation, fell from 48 percent to 12 percent. The patients were on an average of 2.4 medications - fewer than the general adult average of four drugs.
"In general this group wasn't on a lot of medications and had a good prognosis," said Ketter. "The patients were responsive to medication and relatively easy to treat."
Researchers also identified a subset of 13 patients with a first-degree (parent or sibling) family history of bipolar disorder, and found less favorable outcomes. When compared with patients who had no family history of the disease, these patients had more severe prior illness with earlier onset and more hospitalizations, suicide attempts, alcohol abuse and anxiety disorders. The group's average improvement on the CGI was poorer than the other group's, despite being on more medications (3.1 on average) and having been treated for a similar period of time (just under two years).
"When compared to students without a first-degree family history, students with a family history appear to be associated with more severe prior illness, and a poorer longitudinal course," said Ketter. "Further studies are needed to explore these preliminary observations."
Ketter, who received support for his work from the National Institute of Mental Health and the Holland Foundation, is continuing studies on the disorder and plans to investigate the use of brain imaging to predict patients' responses to medications and the use of psychotherapies as alternatives to mood stabilizers.
Ketter's co-investigators in this chart review include Cecylia Nowakowska, MD, PhD; Anna Sapozhnikova; Rebecca Chandler; Andrea Alarcon; Po Wang, MD; and Wendy Marsh, MD.
Stanford University Medical Center integrates research, medical education and patient care at its three institutions - Stanford University School of Medicine, Stanford Hospital & Clinics and Lucile Packard Children's Hospital at Stanford. For more information, please visit the Web site of the medical center's Office of Communication & Public Affairs at http://mednews.