Journal of Psychosocial Nursing and Mental Health Services

Feature Article 

Pediatric Bipolar Disorder: Onset, Risk Factors, and Protective Factors

Ann Roselle, RN, MSN, ACNP-BC

Abstract

The current article discusses the diagnosis of bipolar disorder in children throughout the years as it has evolved, focusing on very early–onset and early-onset bipolar disorder. Proper care of children with bipolar disorder requires a thorough understanding of the subtleties in symptoms at different developmental ages, as well as a shift in diagnostic thinking, which grew to include disruptive mood dysregulation disorder (DMDD). DMDD was added to address potential overdiagnosis of an already unusual diagnosis in young children. Critical discussion of risk factors, protective factors, and lack of data to support protective factors in the literature follows. Implications for advanced practice RNs are included, as these children transition from pediatric practice to adult practice. [Journal of Psychosocial Nursing and Mental Health Services, xx(x), xx–xx.]

Abstract

The current article discusses the diagnosis of bipolar disorder in children throughout the years as it has evolved, focusing on very early–onset and early-onset bipolar disorder. Proper care of children with bipolar disorder requires a thorough understanding of the subtleties in symptoms at different developmental ages, as well as a shift in diagnostic thinking, which grew to include disruptive mood dysregulation disorder (DMDD). DMDD was added to address potential overdiagnosis of an already unusual diagnosis in young children. Critical discussion of risk factors, protective factors, and lack of data to support protective factors in the literature follows. Implications for advanced practice RNs are included, as these children transition from pediatric practice to adult practice. [Journal of Psychosocial Nursing and Mental Health Services, xx(x), xx–xx.]

The diagnosis of bipolar disorder in children is a difficult one to make and not without controversy. Due to perceived overdiagnosis of the disorder, revisions were made in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association [APA], 2013), which included the addition of disruptive mood dys-regulation disorder (DMDD) to allow for the diagnosis of children with a clear affective mood disorder that did not meet clear criteria of bipolar type. Children who are diagnosed with true bipolar disorder must meet full criteria of bipolar disorder as set forth for adults (APA, 2013).

Criteria for diagnosis of bipolar disorder in all ages as defined in the DSM-5 states:

1. Criteria have been met for at least one manic episode (Criteria A-D under “manic episode” below). 2. The occur-rence of the manic or major depressive episode(s) is not better defined by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder or other specified or unspecified schizophrenia spectrum disorder or other psychotic disorder. For a diagnosis of bipolar I disorder, it is necessary to meet the following criteria for a manic episode. The manic episode may have been preceded by or may be followed by hypomanic or major depressive episodes.

Knowledge of bipolar disorder criteria is crucial as children, although developmentally different, are held to the same standards as adults when it comes to diagnostic criteria. Full criteria from the DSM-5 are described in Table A (available in the online version of this article).

Criteria for bipolar episodesCriteria for bipolar episodes

Table A:

Criteria for bipolar episodes

The DSM-5 explores a new definition for children with pervasive mood disorders who do not meet full criteria as described under the diagnosis of DMDD, which is defined predominately by the child's irritability. The child must have:

severe temper outburst occurring three or more times per week. Persistent anger, irritability or sadness between temper outbursts. Onset of symptoms between ages of 6 and 10. Symptoms must be present for a least 12 consecutive months. No signs of mania are present. Temper outbursts or anger, irritability, or sadness are observed in at least two different environments. The symptoms occur absent drug abuse or physical illness.

Advanced practice RNs (APRNs) need to wholly understand the onset of pediatric bipolar disorder, which is broken into very early onset, early onset, adolescent onset, and adult onset. For the purposes of the current article, discussion is limited to very early–onset and early-onset pediatric bipolar disorder, given that general psychiatric consensus with children is that it tends to emerge in the late teenage years. Early onset is defined as diagnosable bipolar disorder in a child ≤18 years old, further subdivided into very early onset, which is diagnosable bipolar disorder in a child ≤12 years old (Connor, Ford, Pearson, Scranton, & Dusad, 2017). There are limitations in such a discussion, as a paucity of data exist for the subgroup of individuals with very early–onset bipolar disorder. Risk factors that are present during childhood for very early–/early-onset pediatric bipolar disorder need to be recognized as well as what protective factors exist within family units to prevent the disorder or delay its onset. It is important to recognize these factors as there is often years-long delay between onset of symptoms to actual diagnosis, complicated by confusion of possible symptoms of other childhood mental disorders (Jenkins, Youngstrom, Youngstrom, Feeny, & Findling, 2012).

Findings

Early-onset bipolar disorder was traditionally considered rare with onset thought to occur in the late teens to late 20s. In the United States, a rapid rise in diagnosis of up to 40 times the previous diagnosis rates has occurred over the past 10 to 15 years (Connor et al., 2017). The addition of DMDD to the DSM-5 seeks to alleviate concerns of false diagnosis from true diagnosis, as APRNs and other clinicians struggle to differentiate bipolar symptoms from those of other childhood mental illness (e.g., attention-deficit/hyperactivity disorder [ADHD], oppositional defiant disorder [ODD] [Blader & Carlson, 2007], anxiety, autism spectrum disorder [ASD] [Hernandez, Marangoni, Grant, Estrada, & Faedda, 2017]).

Meta-analyses have shown hallmark symptoms in early-onset bipolar disorder tend to be increased energy and grandiosity in up to 90% of cases. Irritability and aggression are seen frequently; however, they are called into question as a defining feature despite 80% of cases demonstrating features of irritability (Van Meter, Burke, Kowatch, Findling, & Youngstrom, 2016). The primary argument against irritability is its presence in other childhood mental disorders (Goldstein et al., 2017). Flight of ideas occurs in an average of 56% of early-onset bipolar disorder cases, and hypersexuality is seen in an average of 38% of early-onset bipolar disorder cases (Uchida et al., 2015). Very early–onset bipolar disorder is generally known to be characterized by mania, comorbid neurodevelopmental disorders (e.g., ADHD), rapid cycling courses (Uchida et al., 2015), and decreased global functioning as measured by the global assessment of functioning (Duffy & Malhi, 2017). Decreased need for sleep and psychosis should also trigger evaluation for early-onset pediatric bipolar disorder to distinguish it from other disorders (Youngstrom, Birmaher, & Findling, 2008). In adolescents with bipolar disorder, presentation is typically viewed with major depression first, then onset of mania. Mania in adolescents has higher rates of psychotic features, such as delusions and hallucinations, with grandiosity as a component (Sadock, Sadock, & Ruiz, 2015).

Despite onset and symptoms, what about risk factors for early-onset bipolar disorder? What factors place children at risk for this disorder? Gender tends not to be a risk factor itself, given that bipolar disorder presents in equal rates in male and female children. However, females are more likely to present with bipolar II disorder, and males are more likely to experience manic episodes (Youngstrom et al., 2008).

The single biggest risk factor for children is heritability. To date, bipolar disorder has not been pinpointed to a single gene and is heterogeneous in nature. The larger the familial burden, the bigger the risk factor for a child, which lends itself to an earlier age of presentation and severity of disease course (Youngstrom et al., 2008). Very early–onset bipolar disorder has the highest genetic burden of individuals afflicted with the disorder (Hauser & Correll, 2013). The genome responsible is not known; therefore, studies need to evaluate the etiology of the heritability component given the severity of the disease course (Sadock et al., 2015).

Other known risk factors are familial relationships, such as decreased maternal–child bonding, parental–child tension, impaired peer relationships (Youngstrom et al., 2008), neglect, trauma, abuse, familial disruption, poverty (Daviss, Barnett, Neubacher, & Drake, 2016), and paternal age (Malaspina, Gilman, & Kranz, 2015). Early symptomology of early-onset bipolar disorder can be difficult to distinguish from ADHD; thus, assessing which symptoms are a prodrome or risk factor for later development of bipolar disorder is important. Symptoms that discriminate pediatric bipolar disorder from ADHD are irritability, decreased need for sleep, night terrors, enuresis, and somatic complaints (Hernandez et al., 2017).

In recent years, bipolar disorder has been acknowledged as a spectrum in terms of disease and recognized as affecting myriad ages, particularly with the addition of the very early–onset subgroup. However, there is a split in the psychiatric community as to the subgroups' existence and the need for diagnosis criteria to match that of adults with bipolar disorder. In general pediatrics, the child is viewed as a child and diagnosed according to where they are developmentally and structurally. Keeping that premise in mind, it makes sense to change diagnostic criteria for pediatric bipolar disorder to meet the age groups in question where they are developmentally. Very early–onset bipolar disorder in children is known to have the hallmark of irritability; however, if ODD, ADHD, or ASD have all been successfully ruled out, why complicate the picture with DMDD versus pediatric bipolar disorder?

Protective factors for early-onset bipolar disorder are lack of familial mental illness, a stable family unit, a safe and secure living environment, positive peer support/relationships, a strong maternal bond, no history of abuse or trauma, housing security, and living above the poverty level. Children need to have a loving relationship between themselves and their parents and one that is modeled between the parents (Delaney & Staten, 2010). Research has consistently demonstrated the importance of a strong familial bond as noted in the International Society for Bipolar Disorders Task Force report on pediatric bipolar disorder. In this report, improved parenting skills, flexibility within the family unit, positive family reframing, and most importantly, development of family psychoeducation skills were all demonstrated to be protective factors (Goldstein et al., 2017).

Mental Health America (MHA; 2013) compares and contrasts risk and protective factors from early childhood to early adulthood in children with mental illness. Although they do not specifically address pediatric bipolar disorder, the risk and protective factors can be inferred as it is a mental illness of childhood. MHA focuses on four main categories of importance: health, safety/security, resources, and relationships. Health ensures that the child is protected from toxin exposure, which can affect brain development, obtains adequate sleep, and gets proper nutrition. Safety/security looks at the environment of the child, keeping it free from abuse and exposure to violence. Resources ensures the child has the means to access appropriate housing, health care, nutrition, and education; addresses poverty when feasible; and most critically, obtains mental health services. Relationships looks at the support system of the child. Does the child have appropriate, healthy relationships in his/her life that he/she can rely on and trust? These relationships include parents, peers, teachers, and other caregivers who serve as major supports (MHA, 2013).

The Center for the Study of Social Policy assessed protective factors in the context of adverse childhood events (ACEs) and developed a protective factors framework, entitled The Strengthening Families Approach and Protective Factors Framework (Harper Browne, 2014). The framework specifically spoke to strengthening the family unit as a critical piece in addressing the mental health of a child (Harper Browne, 2014). Five protective factors were identified in the framework: parental resilience, social connections, knowledge of parenting and child development, social and emotional competence of children, and concrete support in times of need. These protective factors are believed to (a) be interrelated; (b) decrease the effects of exposures to risk factors; and (c) create a strong familial bond to allow for optimal child development (Harper Browne, 2014).

It has been argued that the relationship between a child with mental illness (e.g., pediatric bipolar disorder) and his/her parent(s) or family is not a need as determined by Maslow's hierarchy of needs. It can be posited, however, that the relationship is equally critical as a protective factor against mental illness, as demonstrated repeatedly through research. Although a strong familial bond is not essential to life as is air, water, and food, it is essential to healthy brain development and prevention of mental illness or stability of a mental illness (Kenrick, Griskevicius, Neuberg, & Schaller, 2010). Research on outcomes of children who do not have stable homes is outside the scope of the current article, but the ACE study (Schilling, Aseltine, & Gore, 2007) provides data for children who do not have familial stability.

Treatment Implications

Knowledge of risk factors and diagnosis has clinical use in early diagnosis of bipolar disorder. Youngstrom et al. (2008) state there is prognostic value with diagnosis, as children with early-onset diagnosis of bipolar disorder are at higher risk for suicidality (Weinstein, Van Meter, Katz, Peters, & West, 2015), drug use, juvenile criminality, and thus risk of incarceration. Adolescents with bipolar disorder are known to be 30% more likely to attempt suicide or have comorbid psychiatric disorders, such as depression or eating disorders, along with higher lifetime rates of physical/sexual abuse (Knopf, 2017). The rate of suicidal ideation is believed to be 60% higher in youth with bipolar disorder than in youth without bipolar disorder (Weinstein et al., 2015). Children with a mixed episode presented with the greatest risk: 84% of children who reported suicidal ideation were found to have a psychiatric comorbidity, including depression, ADHD, ODD, anxiety, and conduct disorder (Weinstein et al., 2015).

Currently, treatment options are limited for individuals with very early–onset bipolar disorder. There are few U.S. Food and Drug Administration (FDA) –approved medications for the treatment of bipolar disorder in children younger than 12 (Connor et al., 2017). Aripiprazole, quetiapine, and risperidone are FDA-approved for the treatment of bipolar I disorder, manic or mixed moods, in children as young as 10 years old (Centers for Medicare & Medicaid Services [CMS], 2013). Beyond these medications, therapy comprises intensive behavioral therapy with a licensed therapist specializing in children, drawing on collaborations with behavioral interventionists in schools, as these children more than likely have individual education plans within the special education department. Therapy should focus on preventive measures, such as decreasing suicide/suicidal ideation in all ages and improving psychosocial functioning (Goldstein et al., 2017).

Current FDA-approved pharmacology for DMDD is alpha-agonists, such as guanfacine (Tenex®, Intuniv®), which are also used for children with ADHD. In DMDD, these agents decrease irritability, thus, improving mood stability. Guanfacine is thought to stimulate the alpha-2 adrenergic receptors acting on the CYP450 pathway (Epocrates, 2018).

For adolescents with bipolar disorder, the FDA has approved atypical antipsychotic agents and mood stabilizers, such as valproate, lithium, and lamotrigine. An open-label clinical trial is in place for the use of lamotrigine in children. Lithium and valproate received a less robust response in trials where it went toe-to-toe with atypical antipsychotic agents. Lithium and valproate (mood stabilizers) and risperidone, ziprasidone, quetiapine, olanzapine, paliperidone, and aripiprazole (atypical antipsychotic agents) are the only medications approved by the FDA for adolescents with bipolar disorder (CMS, 2013; Sadock et al., 2015).

Functional imaging can be useful for individuals with early-onset bipolar disorder, as magnetic resonance imaging (MRI) and functional MRI have shown structural and functional brain alterations present in this population. Alterations have been found in the pre-frontal cortex and subcortical regions of the brain along with alterations in white matter development. The ability to monitor and assess these changes in children over time (i.e., years) is crucial, as the information can be used to gain knowledge regarding developmental differences compared to controls and how medication can best treat these children (Sadock et al., 2015).

Psychiatric APRNs can benefit from the knowledge presented herein, regardless of the age of their patients. Nurses working with a pediatric population can gain a greater knowledge base of the diseases they are challenged with on a daily basis. For those working with older populations, there are clinical considerations to contemplate. For example, if a patient presents having taken lithium since adolescence, concerns about renal damage may exist much earlier than expected; thus, comprehensive metabolic panels may need to be checked more than once per year to assess renal function. Similar concerns may exist for valproate and liver function. Another example, in terms of practice issues, is if manic episodes have been treated with atypical antipsychotic medications. In these patients, it may be necessary to assess for possible cardiometabolic effects at an earlier age with potential proactive use of metformin to prevent weight gain and support renal protection (GAP Clinical Care and Research Center, 2018). In addition, with the pediatric population, as children and adolescents spend more time on electronic devices and with screens in hand, decreasing their physical activity, APRNs should be cognizant of weights at each visit for individuals taking atypical antipsychotic medications and help families strategize means to increase the patient's physical activity.

Conclusion

In terms of future directions in meeting the needs of this population, the elephant in the room must be addressed—there is no clear definition of very early–onset bipolar disorder. What was previously thought to be very early–onset bipolar disorder is now known as DMDD. This new nomenclature arose in 2009 with its inclusion in the DSM-5 to avoid overdiagnosis of a life-changing, life-long mood disorder in children (Noller, 2016). This nomenclature includes children who are emotionally dysregulated, severely irritable, and often present with ancillary symptoms that include insomnia, agitation, racing thoughts, flight of ideas, and pressured speech (Noller, 2016). The larger question begs to be asked: Is DMDD part of the bipolar spectrum, or is it truly a new disorder of its own right? There are children who meet adult criteria for bipolar disorder; however, there are also children who are diagnosed with DMDD who live in a grey zone, straddling the two worlds. Provider ambiguity regarding diagnosis is also an issue.

The new diagnosis (i.e., DMDD) will ultimately lend itself to overdiagnosis in children once again, as seen with disorders such as ADHD and pediatric bipolar disorder (Margulies, Weintraub, Basile, Grover, & Carlson, 2012). In a study of pediatric inpatients, Margulies et al. (2012) found that diagnosis was highly variable pending observation. Approximately 50% of children were diagnosed with DMDD per parent report, but only 17% met DSM-5 criteria for DMDD while hospitalized per unit physician observation based on exhibited behaviors. Another issue addressed in their study was the common comorbidities that occur with DMDD, including ADHD, ODD, and anxiety, leaving the authors to believe DMDD in itself is not truly a distinct condition (Margulies et al., 2012).

Although studies currently point toward these children being more likely to develop major depression or anxiety in the long term (Sadock et al., 2015), it remains unknown given the amount of data and research on the diagnosis, particularly in terms of how this diagnosis truly evolves over the lifespan. The DSM-5 is now 6 years old, thus, the earliest children with this “new” diagnosis of DMDD are only 10 years into their treatment plans (Noller, 2016). Copeland, Shanahan, Egger, Angold, and Costello (2014) looked at the long-term outcomes of DMDD in children in more than 1,000 individuals, conducting approximately 10,000 assessments throughout childhood into young adulthood. Due to approximately all participants having psychiatric comorbidity, these individuals were found to have more impaired functioning as adults. The authors' single biggest concern surrounded what they termed “pathologizing normal tantrum behavior” (Copeland et al., 2014, p. 674) despite increases in studying the symptoms of irritability in children over the years. They also found rare cases of pure DMDD with no comorbid psychiatric disorders (Copeland et al., 2014).

Regarding the lack of clarity as to where DMDD and bipolar disorder fit together, it has been postulated that “severe mood dysregulation and hyper-arousal symptoms have been conceptualized as a broad phenotype of pediatric bipolar disorder” (Sadock et al., 2015, p. 1242). Clarification of where DMDD sits on the bipolar disorder spectrum can help define treatment/diagnosis for younger children, particularly those thought to have very early–onset bipolar disorder, and refine treatment options. With clearer definitions, more data, earlier interventions, and stronger psychopharmacological knowledge, a less severe course of mood disorder/mental illness over the lifetime may be possible for these children and children with very early–onset bipolar disorder.

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Criteria for bipolar episodes

Manic Episode (ME)Criteria A–D = manic episode. 1 lifetime episode required for diagnosis.
Hypomanic Episode (HE)Criteria A–F = hypomanic episode. Common in bipolar disorder, not required for the diagnosis of bipolar 1 disorder.
Major Depressive Episode (MDE)Criteria A–C = major depressive episode. Common in bipolar 1 disorder but are not required for the diagnosis of bipolar 1 disorder.
MEA.A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least one 1 week and present most of the day nearly every day (or any duration if hospitalization is necessary).
HEA.A distinct period of abnormally and persistently elevated, expansive or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive day and present most of the day, nearly every day.
MDEA.Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous function; at least 1 of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. (Do not include symptoms that are clearly attributable to another medical condition.) 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty or hopeless) or observation made by others (e.g., appears tearful) (In children or adolescents, can be irritable mood) 2. Markedly diminished interest or pleasure in all, or almost all activities most of the day, nearly every day (as indicated by either subjective account or observation) 3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month) or decrease or increase in appetite nearly every day (In children, consider failure to make expected weight gain) 4. Insomnia or hypersomnia nearly every day 5. Psychomotor agitation or retardation nearly every day (observable by others; not merely subjective feeling or restlessness or being slowed down 6. Fatigue or loss of energy nearly every day 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or suicide attempt or specific plan for committing suicide
MEBDuring the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms (four if mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior: 1. Inflated self-esteem or grandiosity 2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep) 3. More talkative than usual or pressure to keep talkative 4. Flight of ideas or subjective experience that thoughts are racing 5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed 6. Increased in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation 7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).
HEBDuring the period of mood disturbance and increased energy and activity, three (or more) of the following symptoms (four if the mood is only irritable) have persisted, represent a noticeable change from usual behavior and have been present to a significant degree: 1. Inflated self-esteem or grandiosity 2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep) 3. More talkative than usual or pressure to keep talking 4. Flight of ideas or subjective experience that thoughts are racing 5. Distractibility (i.e., attention to easily drawn to unimportant or irrelevant external stimuli), as reported or observed 6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation 7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
MDEB.The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
MEC.The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functional or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
HEC.The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic
MDEC.The episode is not attributable to the physiological effects of a substance or another medical condition Note: Responses to a significant loss (e.g. bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgement based on the individual's history and the cultural norms for the expression of distress in the context of loss. The episode is not attributable to the physiological effects of a substance or another medical condition Note: Responses to a significant loss (e.g. bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgement based on the individual's history and the cultural norms for the expression of distress in the context of loss
MED.The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another medical condition.
HED.The disturbance in mood and the change in functioning are observable by others
MDE
ME
HEE.The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features present, the episode is, by definition, manic
MDE
ME
HEF.The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another medical condition. Note: A full hypomanic episode that emerges during antidepressant treatment (e.g. medication, ECT) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a hypomanic episode diagnosis. However, caution is indication so that one or two symptoms (particularly increased irritability, edginess, or agitation following antidepressant use) are not taken as sufficient diagnosis or a hypomanic episode, nor necessarily indicative of a bipolar diathesis.
MDE
Authors

Ms. Roselle is Advanced Practice RN, GAP Clinical Care and Research, Hamden, Connecticut.

The author has disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Ann Roselle, RN, MSN, ACNP-BC, Advanced Practice RN, GAP Clinical Care and Research, 60 Washington Avenue, Suite 203, Hamden, CT 06518; e-mail: a.roselle@gapcare.org.

Received: November 15, 2018
Accepted: February 04, 2019
Posted Online: June 11, 2019

10.3928/02793695-20190531-03

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