Troubles bipolaires chez l'enfant et l'adolescent. Une étude clinique à partir de 50 cas

Progress in knowledge about bipolar disorders, in their clinical, etiological and therapeutic aspects, led these last 20 years to increase the interest for the childhood and adolescence onset forms of these disorders, even if they are rare. In this way, numerous studies emphasized the difficulties encountered in making the diagnosis at this age, mainly because the heterogeneity of the clinical picture observed. In this paper, the authors present the results of a retrospective, descriptive, clinical study performed from 50 cases attended in the Razi hospital child and adolescent psychiatry department in Tunis between 1996 and 2001. Among the 470 adolescents hospitalized in the Razi hospital child and adolescent psychiatry department in Tunis between 1996 and 2001, 50 were diagnosed as having bipolar disorder according to the DSM-IV criteria. Their clinical records were analyzed by means of an epidemiological card drawn from the WASH-U-SADS. Twenty-eight girls and 22 boys were included in the study. The mean age of these subjects at their first hospitalization was 15.8 years; 30% were firstly hospitalized between the age of 14 and 15 years, 24% between the age of 18 and 19 years. The mean duration of their follow-up was 28 months (6-72 months). Forty-four percent of them had previously exhibited episodes of mild depressive manifestations, 16% undiagnosed major depressive disorder, and 14% (only girls) suicide attempts. Familial history of mental disorders was found in 40% of them: non affective psychoses in 18% of the cases, bipolar disorders in 16%, major depressive disorder in 4% and alcohol dependence in 2%. Ninety-four percent of the patients were diagnosed as having bipolar I disorder and 6% bipolar II disorder. The diagnoses at their first hospitalization were very heterogeneous: manic episode in 48% of the cases, major depressive episode with psychotic features in 30%, schizophreniform disorder in 14%, mixed episode in 4%, and adjustment disorder in 4%. The atypical diagnoses were found significantly more frequent in patients firstly hospitalized before the age of 16 years (P < 0.005). During the follow-up, 92 manic episodes were recorded. The analysis of the manic episode clinical features also showed that atypical manifestations (mixed episodes or with psychotic features) were significantly more frequent in the patients firstly hospitalized before the age of 16 years (P < 0.02). Concerning the therapeutic aspects, mood stabilizers were used from the first manic episode in 82% of the cases. The adjunction of an antipsychotic agent during the acute phase of the mood episodes was found relatively frequent, probably because of the frequency of the psychotic features observed during these episodes. These results confirm numerous data previously reported in comparable studies. More particularly, they agree with the recently evoked hypothesis of two separate phenotypes in juvenile bipolar disorders: the early onset forms, in the youngest people, are characterized by an onset usually depressive type and by the occurrence of mood episodes frequently atypical in their clinical and developing aspects; while the later onset forms look almost like the clinical picture usually observed in adulthood. These data also show that it is essential to assess carefully the mood condition in children and adolescents exhibiting atypical pathological episodes.