Megan Sarashinsky, PharmD, BCPP
Clinical Pharmacy Specialist, CJW Medical Center
Pediatric bipolar disorder is surrounded by controversy, including diagnosis and management. Sandra Mullen, PharmD, BCPP, shared her expertise at CPNP 2015 addressing this topic in her session entitled Riding the Roller Coaster: Exploring the Controversy Surrounding the Diagnosis and Treatment of Bipolar Disorder in Children and Adolescents. Dr. Mullen is a Pediatric Psychiatry Clinical Specialist at Virginia Commonwealth University Health System and Assistant Clinical Professor at Virginia Commonwealth University.
Dr. Mullen highlighted controversies regarding the diagnosis of bipolar disorder in children and adolescents, including the criteria used for diagnosis, variations in symptom and episode presentation, contrasts in symptom duration, and differences in outcomes when compared with adults with bipolar disorder.1-6 She also compared and contrasted pediatric bipolar disorder symptoms to other pediatric psychiatric disorders. A considerable symptom overlap is seen with attention deficit hyperactivity disorder, including distractibility, impulsivity, and poor judgement.5,7 Dr. Mullen differentiated the symptoms of pediatric bipolar disorder from disruptive mood dysregulation disorder, highlighting the temper outbursts and persistently irritable mood associated with the latter.4
Dr. Mullen reviewed and compared the two treatment guidelines currently available for the management of pediatric bipolar disorder; these guidelines list treatment modalities including mood stabilizers, antipsychotics, and antidepressants.2-5 A study examining the use of lithium found fewer reports of self-injurious behavior and suicidal ideation when compared with those using other agents.8 A separate study found similar response rates among those taking divalproex, lithium, and carbamazepine.9 A third study described statistically significant response rates in those taking divalproex compared to placebo but not in those taking lithium compared to placebo.10 Studies demonstrating efficacy of aripiprazole, olanzapine, quetiapine, and risperidone when compared to placebo were presented.11-15. In addition, a study comparing mood stabilizers to second generation antipsychotics found no statistically significant differences between the two groups.16
Pediatric bipolar disorder is often underdiagnosed or misdiagnosed, and multiple comorbidities may complicate diagnosis and treatment. A larger body of evidence supports the use of second generation antipsychotics over mood stabilizers but both classes are considered first-line options for the management of pediatric bipolar disorder. Regardless of which regimen is selected, monitoring for response and side effects is necessary.