Prepubertal bipolar disorder: proper diagnosis should lead to better treatment response

Treatment research in prepubertal bipolar disorder remains in a rudimentary stage. Phenomenological evidence suggests it is a heterogeneous disorder with varying degrees of rapid cycling, aggression, and psychosis often accompanied by comorbid diagnoses of attention deficit hyperactivity disorder, conduct disorder, oppositional defiant disorder, and anxiety disorders including obsessive compulsive disorder. Longitudinal and family history studies suggest prepubertal bipolar disorder may be more treatment-resistant than later-onset bipolar disorder. Neurobiological studies to guide treatment, though promising, remain in their infancy. Clinical trials to date (mostly open studies) often have lumped together subjects with manic, hypomanic, and mixed presentations with different and/or undiagnosed comorbidities, making meaningful comparisons of treatment response difficult. Randomized, double-blind, placebo-controlled trials are needed to clarify best treatment options for bipolar subtypes with and without comorbid disorders. More homogeneous diagnostic groupings based on episode and duration criteria and a more patient-centered, symptom-based approach should be considered in treatment designs.