NURS 6660 Week 8 Assignment Paper

NURS 6660 Week 8 Assignment Paper

Diagnosing Pediatric Bipolar Depression Disorder

Among the major presenting symptoms of Bipolar disease, the most common is mood alteration between elation and depressions. Depending on the level of mood elation, this mood can be described as mania or hypomania. The controversy comes in clinically ascertaining the lows of mood, or depression, in children. In all types of bipolar disorders, there are variations in irritability, energization, and education in activity levels.

The diagnostic and statistical manual, fifth edition, (DSM-5) requires that a patient have an alteration of mania and depression in the ratio of at least four days and 2 weeks respectively (Goldstein et al., 2020 NURS 6660 Week 8 Assignment Paper). The depressive episode should be characterized by five or more symptoms of mood depression, lack of pressure and interest, significant weight or appetite loss, purposeless movements, loss of energy, worthless feeling, and lack of concentration.

NURS 6660 Week 8 Assignment Paper

Available Literature, Epidemiological Data, and Diagnosis

According to the National Institute of Mental Health (NIMH), the overall prevalence of bipolar disorders is negligible in children and up to three percent in adolescents (Goldstein et al., 2019 NURS 6660 Week 8 Assignment Paper). The NIMH states that bipolar disease usually starts in adolescence and early stages of adulthood.

The occurrence of bipolar disorder in preadolescence is implied but the relevant research data is negligible. Therefore, I think this makes the diagnosis of childhood bipolar depression inappropriate. Even though the bipolar disease has a genetic component and can run in some families, I support the idea that diagnosing bipolar depression inappropriate and can lead to overdiagnosis and misleading data.

Goldstein, Post, & Birmaher (2019 NURS 6660 Week 8 Assignment Paper) argue the denial of the presence of bipolar disease in children based on the absence of diagnostically agreed criteria leads to underdiagnosis and prolongation of treatment initiation. In contrary to their opinion, think that overdiagnosis of bipolar depression can happen due to other conditions that mimic depression symptoms in children would lead to overtreatment and subjecting the children to various ‘unnecessary’ medical management associated with antidepressants and bipolar disease medications (Goldstein et al., 2020). In the absence of proper and agreeable diagnostic criteria, the epidemiological data cannot be ascertained.

Children Mood and Emotional Health and Development

During early childhood, children can understand the causes of emotions and respond to them appropriately. At the preadolescent stage, children can understand and respond appropriately to the emotions of others through empathy. However, there exist temperamental differences regarding responses to emotions and moods in children (Sadock, Sadock, & Ruiz, 2014). Diagnosis of bipolar disease and bipolar depression requires proper psychiatric history and pertinent mental state evaluation.

The aforementioned diagnostic criteria for adults include some features that cannot be ascertained in children. For example, evaluation of concentration in younger children requires on-point observation skills. Lack of concentration can be a feature of attention deficit and hyperactivity disorder (ADHD) that is very common in children than adults. Including this feature to judge if the children are candidates of major depressive episodes requires proper elimination of other possibilities.

Children who can respond to external mood stimulus such as bereavement may be labeled as depressed when the external stimulus is not taken into consideration. However, distinguishing between normal bereavement and excess mood depression in children has not been established. The misdiagnosis of depression in ADHD on medication patients can also happen (Sadock et al., 2014 NURS 6660 Week 8 Assignment Paper). Other similar disorders such as Disruptive Mood Dysregulation Disorder (DMDD) may be present in a similar way in children (Cichoń et al., 2020).

Alterations in appetite, energy, and interest in children can be results of underlying episodic organic illnesses that cannot be established yet in them. Despite the available set structured diagnostic interview guides for MSE (Sadock, Sadock, & Ruiz, 2014)., implying bipolar depression in a child should be last after elimination of other causes of depression.

At What Stage Should Bipolar Depression be Diagnosed in Children?

The mental growth and development rates vary in children as a result of other external influences including nutritional states, race, and socioeconomic status. This implies that diagnosis of bipolar depression in children can be made difficult by patient characteristics. Children and adolescents have difficulties expressing their emotions verbally. Therefore, it is upon the examiner to interpret the subjective data for diagnosis purposes. Poor interpretation skills may lead to overdiagnosis of bipolar depression by clinicians and overtreatment as mentioned earlier.

Children and adolescents present with emotional lability before the age of ten years. therefore, the DSM-5 only recommended diagnosis of bipolar depression after the age of 10 years. Therefore, bipolar depression can only be implied in the patients who are adolescents who most of the time may not understand their emotions and report subjective data to the clinicians. Relying on the parent’s subjective data about their child for diagnosis also presents a nightmare in the diagnosis process. This is because the parents’ interpretation of the symptoms and behavior of the child may not be based on scientific and psychological knowledge and the frequencies of the symptom’s occurrence may not be accurate.


The controversial discussion surrounding a conventional diagnosis of bipolar depression in children still hang in the balance. Bipolar disease presentation among adults is straight forwards from the adult’s expressions. However, children’s presentation and biological constitution present a dilemma in the diagnosis of bipolar depression. The basic reasons are that the presentation of labile mood is common in children who are necessarily sick, the developmental stages in the children may limit their capabilities to express their emotions and mood accurately making misdiagnosis possible, and other diseases such as ADHD, Disruptive Mood Dysregulation Disorder (DMDD), and organic illnesses present similarly in children. Therefore, the diagnosis of bipolar depression in children is inappropriate and other possibilities should be considered. NURS 6660 Week 8 Assignment Paper

NURS 6660 Week 8 Assignment Paper References

Prevalence and Neurobiology of Bipolar I Disorder

Bipolar I disorder, often known as manic-depressive disorder, is a mental condition characterized by periods of extreme mood elevation and high energy, followed by episodes of depression. The alternating pattern of mania and depression is a hallmark of bipolar disorder. Between mania and depressive periods, people with bipolar I illness may lead regular lives. According to the National Institute of Mental Health (2022), Bipolar I disorder affects approximately 2.5% (6 million individuals) of the population in the United States. The symptoms of bipolar 1 disorder first occur in adolescence or early adulthood, generally before the age of 50. The exact etiology of the disease is unknown; however, neurochemical, genetic, and environmental factors have been implicated to have a role.

Researchers have discovered that brain circuits in various brain parts govern emotions and mood by producing serotonin, norepinephrine, and dopamine (Young & Juruena, 2021; Scaini et al., 2020). The imbalance of neurotransmitters and faulty brain circuit functioning play an important part in the development of bipolar I disorder. Furthermore, a combination of genetics and environmental factors is implicated in developing this disease; hence, the probability of having bipolar I in persons with certain specific genes and close family members with bipolar I is increased. Environmental variables such as chronic severe stress or trauma, feeling overwhelmed, and drug addiction may all contribute to the development of bipolar I disorder.

Bipolar 1 Presentation and its DSM-5 Diagnostic Differences from the Other Types of Bipolar Related Disorder (Bipolar II)


Manic episodes are characterized by euphoria, irritability, and disruptive and aberrant behaviors such as a quick shift of mind from one concept to the next, fast, uninterruptible, and pressured speech, high energy, high activity, grandiosity, drug misuse, egoism, and hypersexuality (APA, 2013). Following a manic episode, depression may occur quickly or later. The majority of people have extended periods without bouts of mania and depression-cycling symptoms, and there are uncommon examples of fast cycling in those with Bipolar I. Another potential for people with bipolar disorder is that their mania and depression moods occur on the same day, which is known as a mixed characteristic. The depressive mood of persons with Bipolar I is similar to that of typical clinical depression, with decreased energy, reduced appetite, suicidal thoughts, low self-esteem, and anhedonia (inability to enjoy pleasure) that lasts for weeks or months but seldom more than a year.

DSM-5 Diagnostic Differences Between Bipolar I and Bipolar II

Bipolar II disorder is the second bipolar-related illness type to which bipolar I will be compared. The manic phase in bipolar 1 is defined by an excessively high, expansive, or irritated mood that lasts at least one week and occurs virtually every day (criteria A), as well as at least three of the following symptoms: increased self-esteem, decreased need for sleep, excessive talkativeness, flight of ideas, easy distractibility, increase in goal-directed activities, and increased involvement in highly pleasurable but dangerous activities such as sex and overspending (criteria B), the symptoms cause marked dysfunction in social, occupational, and other vital areas of functioning (Criteria C), and the symptoms are not attributed to the physiological effects of substance abuse (criteria D) (APA, 2013).

Bipolar 1 may also have a hypomanic phase, in which the symptoms are identical to the manic phase, but the time of excessively high, expansive, or irritated mood lasts at least four consecutive days rather than one full week (APA, 2013). Bipolar 1 may also have a depressive episode, which presents as a low mood with loss of interest, weight loss, insomnia, psychomotor agitation, fatigue, worthlessness, difficulty focusing, and recurring thoughts of death (APA, 2013). While complete manic and depressive episodes characterize bipolar I condition, bipolar II is distinguished by one hypomanic and one full depressive episode, as defined by the DSM-5 diagnostic criteria. The two illnesses may appear in clinically similar ways, necessitating a mental healthcare clinician who is familiar with the DSM-5 diagnostic criteria to identify and establish an accurate diagnosis.

Special Populations and Consideration

Treatment of mental disorders in children and adolescents may be challenging. The first obstacle arises from the difficulty in diagnosing mood disorders since it may be difficult to distinguish, for example, bipolar 1 illness from age-appropriate mood changes (Brickman & Fristad, 2022). The difficulties may result in a decline in the diagnosis of mood disorders in children and adolescents, resulting in inadequate treatment of the illnesses. The second difficulty is that children and adolescents have not reached the legal age of consent and must rely on their parent’s and guardians’ choices to seek care and treatment, which may result in underdiagnosis and undertreatment of mood disorders. 

Pregnancy and postpartum changes are key phases to consider when treating bipolar individuals. Pregnancy and postpartum states have been proven to increase the likelihood of relapse in people with bipolar illnesses owing to hormonal changes during these times (Sharma et al., 2020). Women with bipolar illnesses who are hoping to conceive should engage closely with their mental healthcare specialists to develop methods for properly managing their condition. Because of the increased risk of suicide in the senior population, mood problems may be catastrophic. 

The elderly population has limited social support and affection, which may be related to the loss of loved ones, insufficient financial support due to retirement, and may have difficulty accessing care due to physical immobility or multiple comorbidities, all of which increase their risk of suicidal ideation. To reduce suicidality, elderly people need careful attention and care from mental health professionals as well as accessible family members. In terms of emergency care, bipolar 1 disorder might appear similar to any other mental illness or organic disease, prompting care providers to have a high clinical acumen to avoid missing the diagnosis.

FDA and/or Clinical Guidelines Approved Pharmacological Treatment Options

Bipolar I disorder is treated with mood stabilizers, antipsychotics, and sedative-hypnotics such as benzodiazepines. Lithium, for example, is the widely used mood stabilizer used to regulate largely classical euphoria or manic episodes rather than a depression-mania combination mood at the same time (Hafeman et al., 2020). Before administering lithium, care providers must assess renal and thyroid function and avoid the drug if the baseline organ functions are abnormal. Further, Lithium has a narrow therapeutic window, necessitating cautious prescription and frequent monitoring of the patients on the drug. 

Valproate (antiseizure medicine) may be utilized for quick-acting mood balancing during acute bouts of mania. Valproate (Depakote) is often administered using a loading dosage strategy, which begins with a high dose and results in mood stabilization after a few days of treatment. Other anti-seizer drugs used to treat mania and depression include carbamazepine and lamotrigine. Some antipsychotic drugs, such as Haldol and Thorazine, are used to treat manic and manic-depressive mixed moods. Benzodiazepines, such as Xanax and diazepam, are used for the short-term treatment of acute manic symptoms such as anxiety and sleeplessness; however, benzodiazepines do not address the core symptoms of bipolar I and should only be considered as an adjunct treatment. 

In general, since benzodiazepine medications may be abused and misused by certain patients, doctors must exercise extreme care while administering them. Common antidepressants such as Prozac, Zoloft, and Paxil are ineffective in treating depressive mood in people with bipolar I illness since they may increase manic episodes. The FDA-approved drugs for bipolar I depression include Symbyax (olanzapine-fluoxetine), Lurasidone, Caplyta, Seroquel, and Vraylar. In addition, electroconvulsive therapy (ECT) may be an effective treatment for manic and depressive moods in people with bipolar I.

Bipolar 1 disorder prevention may be difficult due to the unclear nature of its etiology; nonetheless, there are several approaches to reduce the risks associated with bipolar I development. Stress reduction, medications, sleep hygiene management, reducing/stopping alcohol or drug usage, and developing strong friends/family/society support are among the strategies.

Examples of Prescription

  1.     Lithium

Indication: Bipolar disorder

Initial dosage: 1800 mg PO per day divided 8 hourly. Increase the dose as tolerated to target serum lithium concentrations of 0.8-1.2 mEq/L (acute goal) or 0.8-1.0 mEq/L (maintenance goal)

  1.     Fluoxetine

Indication: Depression associated with bipolar 1 disorder, Major depressive disorder

Initial dosage: Fluoxetine 20 mg plus 5 mg Olanzapine PO every night at bedtime. Make dosage adjustments, if indicated, according to efficacy and tolerability within dose ranges of fluoxetine 20-50 mg and olanzapine 5-12.5 mg

  1.     Lurasidone

Indication: Bipolar depression

Initial dosage: Lurasidone 20 mg PO per day initially, may increase the dose if needed, not to exceed 120 mg/day


Mood disorders are among the most common mental diseases that have existed since antiquity. Bipolar and depressive diseases are common mood disorders that gradually debilitate patients. Bipolar disorder is categorized into distinct categories according to the DSM-5 diagnostic criteria, with a narrow line of demarcation. A mental healthcare provider with DSM-5 understanding and good clinical acumen is essential to make correct diagnoses and progress patients’ treatment. Several psychopharmacologic medications show promising results in illness therapy. However, the use of pharmacologic agents may be limited by side effects, patient comorbidities, and patient preferences. Thus, a clinician’s duty in the therapy of mood disorders is to prescribe and justify drugs according to the patient’s requirements.


American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. American Psychiatric Association.

Brickman, H. M., & Fristad, M. A. (2022). Psychosocial treatments for bipolar disorder in children and adolescents. Annual Review of Clinical Psychology, 18(1), 291–327.

Hafeman, D. M., Rooks, B., Merranko, J., Liao, F., Gill, M. K., Goldstein, T. R., Diler, R., Ryan, N., Goldstein, B. I., Axelson, D. A., Strober, M., Keller, M., Hunt, J., Hower, H., Weinstock, L. M., Yen, S., & Birmaher, B. (2020). Lithium versus other mood-stabilizing medications in a longitudinal study of youth diagnosed with bipolar disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 59(10), 1146–1155.

National Institute of Mental Health. (2022). Bipolar disorder. National Institute of Mental Health (NIMH).

Scaini, G., Valvassori, S. S., Diaz, A. P., Lima, C. N., Benevenuto, D., Fries, G. R., & Quevedo, J. (2020). Neurobiology of bipolar disorders: A review of genetic components, signaling pathways, biochemical changes, and neuroimaging findings. Revista Brasileira de Psiquiatria (Sao Paulo, Brazil: 1999), 42(5), 536–551.

Sharma, V., Sharma, P., & Sharma, S. (2020). Managing bipolar disorder during pregnancy and the postpartum period: a critical review of current practice. Expert Review of Neurotherapeutics, 20(4), 373–383.

Young, A. H., & Juruena, M. F. (2021). The neurobiology of bipolar disorder. Current Topics in Behavioral Neurosciences, 48, 1–20.

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