Treatment Options for Bipolar Disorder

Childhood and Adolescent Onset of Bipolar Disorder

Bipolar disorder in children and adolescents is being addressed more intensively and studies are being conducted to investigate safe and effective treatment. The prevalence of bipolar disorder in adolescents is estimated at 1%. However, the prevalence in children is much more difficult to determine partly because symptoms in children may differ subtly from those of adolescents and adults making diagnosis harder to identify. Bipolar disorder in children and adolescents impacts normal child/teenage development, academic performance, relationships, and social/family functioning. As a general rule, symptoms of bipolar disorder in adolescents are more similar to symptoms of bipolar disorder in adults, whereas symptoms of childhood bipolar disorder can be quite different.

Onset of bipolar disorder during childhood and adolescence appears to be a more severe form of bipolar than adult onset and there tends to be more psychosis involved. When the young patients reach their late 20's or early 30's, the manifestations and characteristics of bipolar usually become more typical of adult-onset bipolar disorder. Children and adolescents also tend to experience very rapid mood swings many times a day. Bipolar disorder in youth is usually chronic and is also accompanied by a significant risk for suicide. As with adults, any mention of thoughts about suicide voiced by a child or adolescent with bipolar should be taken very seriously and appropriate help should be sought.

While the criteria for diagnosis in children and adolescents are similar as for adults, (i.e., episodes of mania and depression) children may experience these episodes differently, exhibiting characteristic such as:

• Mixed symptoms
• Rapid-cycling many times a day
• Emotional lability
• Explosive outbursts

Children with bipolar disorder tend to have longer states of irritability, agitation, belligerence and mood lability, rather than discreet episodes. They may exhibit significant aggression during these states. They also have additional problems with attention in general, but especially in school during this time since, the restriction of movement during the day at school exacerbates the agitation.

For many children, the first episode may be major depression and the transition to bipolar states may later develop. It is common to see children experience depressive states in the morning that is followed by increasing energy and mania later in the afternoon or evening. Studies indicate that 33-45% of the children whose first episode is depression develop subsequent episodes of mania or hypomania. Children with mania tend to be more irritable and prone to destructive tantrums versus adults who tend to be elated and happy. Mixed symptoms are also very common in children.

Treatments used for children and adolescents with bipolar disorder are similar to those used for adults, (e.g., medication and counseling). Although there are few studies which have evaluated long term safety and efficacy of medications used by adults, for children those medications are used as the basis of treatment. Treatments used for this population include mood stabilizers, antipsychotics, and electroconvulsive therapy (ECT).

Family history of affective or mood disorders is a significant predictor of bipolar disorder in prepubertal children who experience at least one episode of major depression. In a study of 37 families in which at least one parent had bipolar disorder, 51% of their offspring had psychiatric disorders; 28% were diagnosed with ADHD, approximately 15% were diagnosed with bipolar disorder and another 15% with major depression.

When parents are interviewed, many report that their children seemed different already in childhood. They may have exhibited behaviors including:

• Being over-responsive to stimulation
• Difficulty settling down
• Sleep disturbances and night terrors
• Hyperactivity
• Difficulty making changes
• Anxiety
• Difficulty controlling anger
• Prolonged and violent temper tantrums

There are several conditions that present with similar symptoms to bipolar disorder which should be considered in the differential diagnosis or which may present simultaneously with bipolar. Conditions to be considered include:

• ADHD
• Conduct disorders
• Substance abuse
• Schizophrenia
• Anxiety disorders
• Tourette's syndrome
• Oppositional defiant disorder (defiance of authority, physical aggression and verbal abuse.

It is estimated that approximately 50-98% of children and adolescents who develop bipolar disorder also have signs of attention deficit hyperactivity disorder (ADHD). Some children also present with obsessive compulsive disorder (OCD), or some type of conduct disorder. In treating these children, it is important to treat the bipolar disorder first since stimulant medications which are often given for ADHD can have an adverse effect on bipolar disorder.

Some of the symptoms which bipolar disorder and ADHD share in common include destructiveness, temper tantrums, and behavior problems. Following temper outbursts, children with ADHD may settle down after approximately 30 minutes whereas children with bipolar may remain angry for several hours. Symptoms such as sleep disturbances, irritability, and night terrors from frightening dreams are associated with bipolar but not with ADHD.

Other symptoms which appear in children and adolescents include anxiety disorders and panic disorders (approximately 30%), substance abuse (approximately 40%), and suicide ideation (approximately 25%). Substances abused the most include:

• Alcohol
• Marijuana (cannabis)
• Cocaine
• Stimulants

It has been estimated that approximately 55% of children with bipolar disorder who recover from mania, experience relapse and up to 20% of the adolescents may attempt suicide. A strong predictor of recovery in children/adolescents with bipolar disorder is an intact family structure.

Lithium

Lithium carbonate is the most widely studied drug for bipolar disorder in children. The response rate ranges from 50-100%. Lithium is effective as a single agent and also when combined with other classes of drugs. Improvement has also been noted in studies involving youth with bipolar disorder and comorbid substance abuse as well as psychotic mania. Side effects of lithium in children are the same as for adults.

Divalproex Sodium

Studies of children with manic, hypomanic or mixed symptoms reported that approximately 60% of the children and adolescents improved with divalproex. Some studies indicate that divalproex sodium may be even more effective than lithium but there are no definitive conclusions. Side effects of divalproex sodium in children and adolescents with Polycystic Ovary Syndrome (PCOS) are similar as for adults.

Other medications for children with bipolar disorder that may be used include those used as second-line treatments for adults.

Electroconvulsive Therapy (ECT)

Results of a small study reported in the American Journal of Psychiatry indicated that approximately 80% of adolescents under the age of 18 with signs of mania who were treated with ECT responded positively and had significant symptom improvement.