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. Author manuscript; available in PMC: 2021 Apr 1.
Published in final edited form as: J Psychiatr Res. 2020 Jan 25;123:48–53. doi: 10.1016/j.jpsychires.2020.01.010

Characteristics of youth at high risk for bipolar disorder compared to youth with bipolar I or II disorder

Marc J Weintraub 1, Christopher D Schneck 2, Patricia D Walshaw 2, Kiki D Chang 3, Manpreet K Singh 4, David A Axelson 5, Boris Birmaher 6, David J Miklowitz 1
PMCID: PMC7047576  NIHMSID: NIHMS1560814  PMID: 32036073

Abstract

Significant efforts have been undertaken to characterize the phenomenology of the high-risk period for bipolar disorder (BD) through the examination of youth at familial risk (i.e., having a first- or second-degree relative with BD) or clinical high risk for the disorder (i.e., youth with BD Not Otherwise Specified [NOS] or major depressive disorder [MDD]). However, little is known about the phenomenology of youth at both familial and clinical high risk for BD. In this study, we examined the clinical and psychosocial characteristics of youth at familial and clinical high risk (HR) for BD, and compared these characteristics to those of youth with BD I and II. Both groups were recruited based on current, active mood symptoms from separate randomized trials of family therapy. A total of 127 HR youth were evaluated: 52 (40.9%) were diagnosed with BD-NOS and 75 (59.1%) were diagnosed with MDD. Compared to adolescents with BD I and II (n=145), HR youth had higher rates of anxiety disorders, and comparable rates of attention-deficit/hyperactivity disorder and oppositional defiant disorder/conduct disorder. Mood symptom severity and psychosocial functioning were progressively more impaired consistent with diagnostic severity: BD I>BD II>BD-NOS>MDD. Nonetheless, HR youth exhibited significant depressive symptom severity compared to adolescents with BD I and overall impairment in psychosocial functioning. These results provide further support for the high rates of anxiety disorders and premorbid dysfunction in addition to active mood symptoms for youth at risk for BD, and suggest anxiety is an important phenological characteristics and treatment target of the high-risk period.

1. Introduction

Bipolar disorder (BD) is increasingly conceptualized as a neurodevelopmental disorder that shows its first clinical manifestations years prior to syndromal onset (Van Meter et al., 2016). Significant efforts have been undertaken to better understand the prodromal period of BD (e.g., Birmaher et al., 2018). For about 65% of individuals with BD, the illness begins prior to age 18, and the first emergence of symptoms occurs an average of 10 years prior to reaching full threshold for the illness (Perlis et al., 2004; Shaw et al., 2005). The period before the onset of the disorder represents a critical window for clinical intervention, as earlier age of onset, psychiatric comorbidities, and delays to treatment are associated with longer and more severe courses of illness (Birmaher et al., 2014; Post et al., 2010; Weintraub et al., 2019).

Most studies have classified risk for BD based on either family history (a bipolar diagnosis in first- or second-degree relative) or clinical risk (depression, hypomania, mood instability or a diagnosis of unspecified BD (or BD Not Otherwise Specified [NOS]) (e.g., Axelson et al., 2006; Duffy et al., 2018). Youth at clinical high risk show significant mood symptoms, risk for suicidal behaviors and substance abuse, and impairment despite episodes that are shorter than the time required to meet DSM-5 criteria for a manic, hypomanic or depressive episode (Axelson et al., 2011; Findling et al., 2005; Goldstein et al., 2013; Goldstein et al., 2012; Hafeman et al., 2013). These at-risk populations also present with non-specific and heterogeneous forms of psychopathology: anxiety disorders, attention-deficit/hyperactivity disorder (ADHD), oppositionality, or other psychiatric conditions (Axelson et al., 2011; Duffy et al., 2014).

To expand upon our understanding of risk for BD, we examined the clinical and psychosocial characteristics of youth (ages 9–17) who were at high clinical and familial risk for BD. The participants were diagnosed with BD-NOS or major depressive disorder and had at least one first- or second-degree relative with BD I or II. We compared these high-risk youths’ characteristics to those of adolescents (ages 12–18) with established BD I or II. Both sets of youth were recruited for one of two trials of family-focused treatment (FFT), and entered these trials with a subsyndromal or syndromal mood episode. We examined differences between diagnostic groups on demographic characteristics, mood symptom severity, age of onset of mood symptoms, comorbid disorders, psychiatric medications, and global functioning. We hypothesized that high-risk youth would have less severe psychiatric impairment, and better psychosocial functioning compared to youth with BD I and II. Additionally, based on previous findings of the development of BD (Duffy et al., 2014), we hypothesized that youth at high-risk for BD would have a higher proportion of psychiatric comorbidities, particularly anxiety, compared to youth with BD I/II disorder.

2. Methods

2.1. Participants

To be eligible for the study of FFT for high-risk (HR) youths, participants had to be 9–17 years old, meet lifetime DSM-IV-TR criteria for BD-NOS (termed unspecified BD in the DSM 5) or MDD, have at least one first- or second-degree relative with a lifetime diagnosis of BD I or II, and have a current mood episode in the moderate or more severe range (a score of > 11 on the Young Mania Rating Scale (YMRS; Young et al., 1978) over the prior week or a score of >29 on the Child Depression Rating Scale (CDRS; Poznanski and Mokros, 1996) over the past 2 weeks). To increase the likelihood of identifying youth with recurrent manic symptoms, criteria for unspecified BD was based on distinct periods of abnormally elevated, expansive or irritable mood plus two (three, if mood only irritable) DSM symptoms of mania causing a change in functioning, lasting ≥ 4 hours in a day and occurred for at least 10 or more days in the youth’s life (Birmaher et al., 2018; Miklowitz et al., 2017).

To be eligible for the trial of FFT for adolescents with bipolar I or II disorder, the youth had to be 12–18 years old, meet DSM-IV-TR diagnostic criteria for bipolar I or II disorder, have a hypomanic/manic episode or mixed episode lasting at least one week or a major depressive episode lasting at least 2 weeks within the past 3 months, and have current active mood symptoms (≥17 on the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) Mania Rating Scale or ≥16 on the K-SADS Depression Rating Scale for at least 1 week over the past month) (Axelson et al., 2003; Chambers et al., 1985; Kaufman et al., 1997). Participants also had to be willing to engage in pharmacotherapy with a study psychiatrist. Exclusion criteria for both studies included current substance abuse or dependence, pervasive developmental disorder, or current physical or sexual abuse requiring treatment outside of the protocol.

2.2. Procedure

The HR trial was conducted across three sites: University of California, Los Angeles (UCLA) School of Medicine, Stanford University School of Medicine, and University of Colorado, Boulder/Anschutz Medical Campus. The pediatric BD trial was conducted at the University of Colorado, the University of Pittsburgh School of Medicine, and the Cincinnati’s Children’s Hospital Medical Center. Participants and their parent(s) received a full explanation of the study procedures before giving written assent/consent to participate. All sites received approval from their medical institutional review boards.

For both studies, a semi-structured assessment of participants’ current and lifetime psychiatric diagnoses was conducted using the K-SADS, Present and Lifetime version (Kaufman et al., 1997). KSADS diagnoses were based on child- and parent-report followed by consensus ratings made by trained MA and PhD diagnosticians. Diagnoses that were assessed included depressive disorders, bipolar disorders, anxiety disorders (i.e., panic, agoraphobia, specific phobias, social anxiety, generalized anxiety, separation anxiety, post-traumatic stress disorder, and obsessive-compulsive disorder), oppositional defiant disorder, conduct disorder, attention-deficit/hyperactivity disorder, and substance use disorders (for purposes of exclusion). Inter-rater reliability for the KSADS depression and mania scores were 0.74 and 0.84, respectively, in the HR study and 0.89 and 0.81, respectively, in the adolescent BD study. K-SADS depression and mania total scores (each comprise 13 items rated on 1–7 scales of severity and impairment) were used as measures of current mood symptom severity.

Global functioning over the previous two weeks as well as highest functioning over the past year was measured via a clinician rating on the Clinical Global Assessment Scale (CGAS; Shaffer et al., 1983). Family socioeconomic status was measured using the Hollingshead SES Scale (Hollingshead, 1975). Medication exposure was summarized in terms of prescribed or not prescribed for each psychotropic class (i.e., antidepressants, anticonvulsants, antipsychotics, lithium, stimulants). Suicidal ideation was measured using the Suicidal Ideation Questionnaire in the HR sample only (Reynolds, 1987).

Psychiatric history of the youths’ biological first- or second-degree relatives was examined using the MINI-International Neuropsychiatric Interview for family members present at the assessment (Sheehan et al., 1998). First- or second-degree relatives suspected of having BD I or II who were not available to be interviewed directly were diagnosed based on the secondary reports of the parent who completed the KSADS interview, using the Family History Screen Instrument (Weissman et al., 2000). Of note, youth in the high-risk sample had to have at least one first- or second-degree relative with bipolar I or II disorder, as documented with a direct MINI interview. This criterion was not required for youth in the BD I/II sample, where secondary reports based on the Family History Screen were the main source of family history data. Thus, rates of familial illness were lower in the BD I/II sample because of differences in inclusion criteria and ascertainment methods. Nonetheless, rates of family history for BD in the BD I and II sample were comparable to rates observed in other studies of pediatric BD (e.g., 36.8% by Birmaher et al., 2009).

2.3. Statistical Analyses

First, we examined the sample characteristics of HR youth, including demographic variables (age at intake, SES, gender, race, ethnicity), clinical variables (age of mood disorder onset and mood symptom severity, number of psychiatric comorbidities, medication exposure), and global functioning. We then compared the study participants (stratified based on youths’ specific diagnosis – BD I, BD II, unspecified BD, or MDD) on the aforementioned demographic, clinical and psychosocial variables. For continuous variables, groups were compared using analyses of variance (ANOVA). For categorical variables (i.e., psychiatric medications, psychiatric comorbidities, gender, race, and ethnicity), groups were compared using chi-square tests. We then re-conducted the aforementioned analyses of clinical and psychosocial characteristics, but controlling for age at baseline, due to there being differing inclusion criterion on age between the two samples.

3. Results

3.1. Characteristics of Youth at High-Risk (HR) for BD

3.1.1. Demographics.

The HR study consisted of 127 participants with an average age of 13.2 years (SD=2.6) and who were primarily middle class, female (64.6%), and White (81.9%). The majority of youth (82.7%) had a first-degree relative with full threshold BD. The full demographics and clinical characteristics of the HR sample are presented in Table 1.

Table 1.

Demographic, clinical, and psychosocial characteristics of youth at high risk for BD (n=127)

Demographics
Mean SD
Age at intake 13.2 2.6
SES 46.0 9.8
N %
Female participants 82 64.6
Minority participants 23 18.1
Hispanic participants 23 18.1
Clinical and Psychosocial Characteristics
Mean SD
Age of MDE onset 11.9 2.5
Age of hypomanic onset* 11.0 3.1
K-SADS Depression Rating Scale 22.3 8.7
K-SADS Mania Rating Scale 14.2 9.2
Suicidal ideation questionnaire 36.7 22.8
CGAS – past two weeks 53.5 10.3
CGAS – highest functioning in past year 64.6 10.9
Number of comorbidities 1.7 1.0
N %
First-degree family history of BD 105 82.7
Primary Mood Diagnosis
 Major Depression 75 59.1%
 Bipolar NOS 52 40.9%
Comorbid Psychiatric Disorders
 Anxiety disorders 81 63.7
 ADHD 49 38.6
 Eating disorder
 ODD/CD 32 25.2
 Past substance abuse/dependence 5 3.9
 No comorbidities 18 14.2
Psychotropic Medications
 Anticonvulsant 17 13.4
 Antidepressant 44 34.6
 Antipsychotic 30 20.8
 Lithium 1 0.8
 Stimulant 23 18.1
 Any psychotropic 67 52.8
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ADHD = attention-deficit/hyperactivity disorder; BD = bipolar disorder; CGAS = Clinical Global Assessment Scale; K-SADS = Kiddie Schedule for Affective Disorders and Schizophrenia; MDE = major depressive episode; ODD/CD = oppositional disorder/conduct disorder; PTSD = post-traumatic stress disorder; SES = socioeconomic status.

*

Values indicate age of onset for hypomanic symptoms that meet criteria for BD-NOS; analysis excluded high-risk youth with major depressive disorder.

3.1.2. Clinical and Psychosocial Characteristics.

The majority (59.1%) of the HR youth met criteria for major depressive disorder, compared to 40.9% meeting our criteria for BD-NOS. The MDD and BD-NOS youth did not differ in their age of first depressive mood onset. In the subsample with BD-NOS, there was no difference in age of onset between first major depressive episode and age of hypomanic onset.

The HR youth had an average of 1.7 (SD=1.0) psychiatric comorbidities. Anxiety disorders were the most common comorbidity, with 63.7% meeting criteria for an anxiety disorder, with no differences between youth with BD-NOS versus MDD. Only 14.2% of HR youth had no psychiatric comorbidities secondary to a mood diagnosis. Based on the 100-point scale on the CGAS in the two weeks prior to the study intake, mean global functioning in youth was 53.5 (SD=10.4) and highest level of functioning in the past year was a mean of 64.6 (SD=10.9), with no differences between youth with BD-NOS versus MDD.

3.2. Comparison of Youth at Risk for BD to Youth with BD

3.2.1. Demographics.

When comparing specific mood diagnoses (i.e., BD I, II, BD-NOS, and MDD) on age at intake, youth with BD-NOS began their illnesses at the youngest age, whereas youth with BD I and II began at oldest ages (F(3,267)=35.89, p<0.001; Table 2). There were no differences between diagnoses on SES, gender, or proportion of ethnic or racial minority participants.

Table 2.

Demographic, clinical and psychosocial characteristics across bipolar spectrum

Bipolar I Disorder (n=77) Bipolar II Disorder (n =68) Bipolar NOS (n =52) Major Depressive Disorder (n =75)
Demographics
Mean SD Mean SD Mean SD Mean SD p
Age at intake 15.4a 1.4 15.9a 1.4 12.6b 2.6 13.6C 2.3 <0.001
SES 42.9 14.4 43.5 14.5 48.1 8.9 44.6 10.2 0.14
N % N % N % N % P
Female participants 39 50.6 28 41.2 37 71.2 45 60.0 0.14
Minority participants 13 16.9 11 16.2 10 19.2 13 17.3 0.98
Hispanic participants 6 7.8 6 8.8 10 19.2 13 17.2 0.11
Clinical and Psychosocial Characteristics
Mean SD Mean SD Mean SD Mean SD p
Age of MDE onset 13.3a 2.5 14.1a 2.2 11.3b 2.6 12.2b 2.4 <0.001
Age of (hypo)manic onset 13.2a 2.5 14.4b 2.7 11.0c 3.1 - - <0.001
K-SADS Depression Rating Scale 23.9a 12.0 27.4b 9.0 20.8a 9.6 23.4a 8.1 0.004
K-SADS Mania Rating Scale 31.4a 11.5 25.6b 10.4 20.3c 8.4 10.1d 7.3 <0.001
CGAS – Past two weeks 37.6a 7.5 44.0b 6.9 55.2C 10.4 52.2c 10.2 <0.001
CGAS – Highest functioning in past year 60.5a 8.6 61.9a,b 8.1 64.0b 10.5 65.0b 11.3 0.03
Number of comorbidities 1.2a 1.1 1.2a 1.0 1.8b 1.0 1.6b 0.9 0.003
N % N % N % N % p
First-degree family history of BD+ 8 29.6a 9 32.1a 45 86.5b 60 80.0b <0.001
Comorbid Psychiatric
Disorders
 Anxiety disorders 25 32.5a 32 47.1a,b 34 65.3c 47 62.7b,c <0.001
 ADHD 27 35.1 21 30.9 22 42.3 27 36.0 0.6
 ODD/CD 27 35.1 15 22.1 17 32.7 15 20.0 0.1
 Past substance abuse/dependence 8 10.3 10 14.7 1 1.9 4 5.3 0.06
 No comorbidities 33 42.9a 21 30.9a 6 11.5b 12 16.0b <0.001
Psychotropic Medications
 Anticonvulsant 11 14.3a,b,c 5 7.4c 12 23.lb 5 6.7a,c 0.01
 Antidepressant 13 16.9a 14 20.6a,b 16 30.8b,c 28 37.3c 0.006
 Antipsychotic 61 79.2a 31 45.6b 16 30.8b,c 14 18.7c <0.001
 Lithium 17 22.0a 7 10.3a 0 0.0b 1 1.3b <0.001
 Stimulant 12 15.6 8 11.8 9 17.3 14 18.7 0.6
 Any psychotropic 73 94.8a 49 72.1b 28 53.8b,c 39 52.0c <0.001
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Note: Each superscript letter within a row denotes classes whose means do not significantly differ from each other at the p<0.05 level. ADHD = attention-deficit/hyperactivity disorder; BD = bipolar disorder; CGAS = Clinical Global Assessment Scale; K-SADS = Kiddie Schedule for Affective Disorders and Schizophrenia; MDE = major depressive episode; ODD/CD = oppositional disorder/conduct disorder; PTSD = post-traumatic stress disorder; SES = socioeconomic status.

+

= Percentages of first-degree history of BD for youth with BD are based on available data for 27 BD I youth and 28 BD II youth.

3.2.2. Clinical Characteristics.

Both of the HR groups (i.e., MDD & BD-NOS) had their first onsets of major depression earlier than youth with BD I or II (F(3,212)=12.55, p<0.001; see Table 2). Additionally, the age of hypomania onset that met criteria for BD-NOS in BD-NOS youth was younger than the age of hypomanic/manic onset in youth with BD I and II (F(2,173)=18.57, p<0.001). However, the majority (94.5%) of BD-NOS youth experienced only subthreshold hypomania, compared to all of the BD I/II youth having had experienced full threshold hypomania or mania.

Regarding current mood symptom severity on the K-SADS (see Table 2), the BD I group had the most severe manic symptoms, followed by the BD II group and the unspecified BD group (F(3,263)=64.83, p<0.001). The MDD youth had the least severe manic symptoms. The BD II youth had higher K-SADS depressive scores than youth in the other groups (F(3,264)=4.47, p=0.004).

3.2.3. Global Functioning.

Over the two weeks prior to intake, global functioning was lowest for the BD I youth, followed by the BD II youth; the HR groups had the highest functioning (F(3,229)=49.41, p<0.001; see Table 2). In the year prior to intake, highest global functioning was only lower for the BD I youth compared to both of the HR groups (F(3,245)=2.95, p=0.03).

3.2.4. Psychiatric Comorbidities.

Both HR groups had a higher number of psychiatric comorbidities compared to the youth with BD I or II (F(3,268)=4.86, p=0.03; see Table 2). Youth with BD-NOS and MDD had high proportions of comorbid anxiety disorders (63.8% and 62.7%, respectively) followed by youth with BD II (47.1%), and youth with BD I (32.5%; χ2(3)=19.39, p<0.001). Both the BD I and II youth had higher proportions of youth without any psychiatric comorbidities compared to the HR subsamples.

3.2.5. Psychopharmacotherapy.

Youth with BD represented a larger proportion of youth prescribed any psychotropic medications compared to the HR sample (χ2(3)=32.77, p<0.001). There were no specific hypotheses for medication use, but the differences between diagnostic groups based on specific psychotropic categories are presented in Table 2.

3.2.6. Sensitivity analysis—controlling for age.

The relationship between mood diagnosis and age of mood onset was no longer significant when controlling for baseline (current) age. There was high collinearity between baseline age and age of mood onset(s) (Pearson rs: 0.6–0.7). Controlling for current age also removed the statistical differences between mood diagnosis and K-SADS depression severity. However, all other statistical tests remained unchanged when controlling for age.

4. Discussion

This study examined the clinical characteristics of youth at familial and clinical high risk to BD and compared them to those of adolescents diagnosed with BD I and II. The high-risk youth presented with active depressive symptoms and, for the BD-NOS youth, hypomanic symptoms (Axelson et al., 2011; Hafeman et al., 2016), as well as significant psychiatric comorbidities (most notably anxiety disorders). The high-risk youth also exhibited “variable functioning with sporadic difficulties” (difficulties in several but not all areas), as characterized on the CGAS for individuals scoring in the range of 51–60 (Shaffer et al., 1983). These clinical characteristics are consistent with studies of the longitudinal development of youth at familial risk for BD, which find that anxiety, depression, and impaired premorbid adjustment precede the onset of full threshold BD (Duffy et al., 2018).

The adolescents with full threshold BD had more severe mood symptoms and poorer current functioning compared to the at-risk youth; however, the diagnostic groups were comparable in highest levels of functioning in the past year. These findings are consistent with previous findings that at-risk youth share similar characteristics to full threshold BD, despite having a less severe symptomatic presentation (Hafeman et al., 2013). In particular, individuals with BD-NOS have been considered more similar to BD I and II individuals than different (Angst et al., 2010; Axelson et al., 2006). The clinical characteristics found in this study also provide further evidence for clinical stages of development in BD (Berk et al., 2007; Kapczinski et al., 2009). Investigators have begun to describe the development of BD in distinct clinical stages, from increased risk (e.g., familial risk) without mood symptoms, to prodromal mood features, to full threshold BD. Consistent with the staging model, the BD-NOS youth had impaired functioning, active depressive symptoms, and active hypomanic symptoms, yet had less severe psychiatric symptoms and better current functioning than the BD I and II youth.

Both of the high-risk groups (MDD and BD-NOS youth) had a younger age of onset of major depressive episodes compared to the BD I and II adolescents, although this relationship was no longer significant when we controlled current age. We see value in future studies that examine whether youth who develop subthreshold symptoms at younger ages differ from those with later ages at onset with respect to course of illness or treatment response, independent of the youth’s current age.

This study found high rates of psychiatric comorbidity among both youth with and at-risk for BD, which has been found in previous work in pediatric BD samples (Axelson et al., 2011; Hafeman et al., 2013) and in samples of offspring of parents with BD (Goldstein et al., 2010). The rates of ADHD and ODD/CD (about 1 of 3 for both categories) were consistent with an epidemiological sample from the world health initiative (Merikangas et al., 2011). The rates of comorbid anxiety disorders were particularly high, with close to 2 in 3 of both the MDD and BD-NOS high-risk youth in this study meeting criteria for an anxiety disorder compared to about 40% in the BD I and II sample. Previous work has indicated that rates of anxiety are significantly elevated among offspring of bipolar parents compared to controls (Duffy et al., 2007; Goldstein et al., 2010). Thus, anxiety disorders may constitute part of the early developmental presentation of BD, and represent an important early treatment target for symptomatic youth at familial risk for BD (Duffy et al., 2018; Duffy et al., 2014).

A substantial proportion of the high-risk with BD-NOS and the majority of the high-risk youth with major depression will likely not develop full-threshold BD (Axelson et al., 2011). Regardless of conversion to BD, psychiatric comorbidities are prone to persist, as is seen in prodromal psychosis populations (Addington et al., 2011). In addition to managing mood symptoms, addressing comorbid anxiety through psychological or pharmacological treatment appears central to addressing the psychiatric needs of high-risk youth. Considering the high-risk period consists of heterogenous mood/anxiety, mood lability and subsyndromal manic symptoms, transdiagnostic cognitive-behavioral skills may be useful for this at-risk population (Weintraub et al., in press).

Although this study is cross-sectional and based on a treatment-seeking sample, these results have implications for the development of BD, particularly for individuals with familial bipolar risk. First, psychiatric comorbidities stand out as an important phenomenological characteristic of these high-risk states. Psychiatric characteristics (notably mood symptom severity and functioning, and comorbidities) Second, across the BD spectrum (from high risk states to full threshold BD), functional impairment worsens as manic symptoms become more severe. Further research is needed to more accurately assess the stages of bipolar illness as well as staging of treatment recommendations. Managing the current symptoms and dysfunction of the youth, together with enhancing individual and family coping skills to reduce the risk for future psychiatric disorders, is a frame that will be appreciated by families coping with an ill offspring (Miklowitz, 2015; Post et al., 2013).

Funding information:

Financial support for this study was provided by National Institute of Mental Health (NIMH) grants R01MH093676, R01MH073871, R01MH073817, R01MH074033, R01MH093666, R34MH077856, and R34117200.

Disclosures:

The authors declare no conflicts of interest. Dr. Weintraub receives research support from Aim for Mental Health and the Shear Family Foundation. Dr. Schneck receives research support from the NIMH and the Ryan White HIV/AIDS Treatment Extension Act. Dr. Walshaw has no disclosures. Dr. Chang is a consultant for Sunovion, Allergan, and Impel Neuropharma; he is also on the speakers’ bureau for Sunvion. Dr. Singh receives research support from Stanford’s Maternal Child Health Research Institute, National Institute of Mental Health, National Institute of Aging, Johnson and Johnson, Allergan, and the Brain and Behavior Research Foundation. She is on the advisory board for Sunovion, is a consultant for Google X and Limbix, and receives royalties from the American Psychiatric Association Publishing. Dr. Axelson receives royalties from UpToDate and has served as a consultant for Janssen Research. Dr. Birmaher has received research support from NIMH and receives royalties from Random House, Lippincott Williams & Wilkins, and UpToDate. Dr. Miklowitz has received research funding from the NIMH, Brain and Behavior Research Foundation, Attias Family Foundation, Danny Alberts Foundation, Carl and Roberta Deutsch Foundation, Kayne Family Foundation, Max Gray Foundation, American Foundation for Suicide Prevention, and AIM for Mental Health. He receives book royalties from Guilford Press and John Wiley & Sons.

Footnotes

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