Treatment Implications

Early detection of prodromal symptoms or signs in high-risk populations offers a window of opportunity for preventive and therapeutic interventions (psychotherapy as well as pharmacotherapy), and allows avoidance of treatments (antidepressants, stimulants) which may worsen the clinical course of the disorder [37].

Psychoeducational as well as psychotherapeutic interventions on children and their parents (either affected or not) can help them to manage life experiences or family stressors. On the pharmacological side, lithium did not result to be superior to placebo in the treatment of 30 prepubertal children with depression and a positive family history of mood disorders (40% with a parent with bipolar disorder, 40% with a more distant bipolar familiality and 20% with family history of major depression only) [92]. Divalproex has been openly studied in bipolar offspring with mood or behavioural disorders and mild affective symptoms, but without a fullblown bipolar disorder [93]: of the 23 subjects who completed the study, 18 (78%) were considered responders according to the Clinical Global Impression (CGI) improvement score (very much or much improved). The majority of responders improved within the first 4 weeks of treatment. These preliminary findings suggest a possible preventive pharmacological intervention in a high-risk population not yet with a fully developed bipolar disorder.

Methodological issues of an ongoing 8-week, randomized, placebo-controlled study with antikindling agents in 60 bipolar offspring with either cyclothymia or bipolar disorder not otherwise specified have been reported [94], but results are still not available. Donovan et al. [95] did report in a small double blind study that explosive and labile moods in adolescence falling short of clear-cut criteria for bipolarity responded to valproate.

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