Bipolar Disorder in Children and Adolescents

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Megan Sarashinsky, PharmD, BCPP
Clinical Pharmacy Specialist, CJW Medical Center
Richmond, VA

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.

Current Diagnosis Controversies

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

Evidence of Medication Efficacy

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

Take Home Messages

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.

References

  1. Kowatch RA et al. Pediatric bipolar disorder: emerging diagnostic and treatment approaches.  Child Adolesc Psychiatry Clin N Am. 2006;15:73-108.
  2. McClellan J et al. Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder.  J Am Acad Child Adolesc Psychiatry. 2007;46(1):107-25.
  3. Leibenluft E et al. Defining clinical phenotypes of juvenile mania.  Am J Psychiatry. 2003;160(3):430-7.
  4. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013.
  5. Kowatch RA et al.  Review and meta-analysis of the phenomenology and clinical characteristics of mania in children and adolescents. Bipolar Disord. 2005;7(6):483-96.
  6. Birmaher B et al. Clinical course of children and adolescents with bipolar spectrum disorders. Arch Gen Psychiatry. 2006;63(2):175-83.
  7. Wozniak J et al. Mania-like symptoms suggestive of childhood-onset bipolar disorder in clinically referred children.  J Am Acad Child Adolesc Psychiatry. 1995;34(7):867-76.
  8. Ko, et al. Clinical characteristics associated with lithium use among adolescents with bipolar disorder.  J Child Adolesc Psychopharmacol. 2014;24(7):382-9.
  9. Kowatch RA et al. Effect size of lithium, divalproex sodium, and carbamazepine in children and adolescents with bipolar disorder. J Am Acad Child Adolesc Psychiatry. 2000;39(6):713-20.
  10. Cincinnati Children’s. Large controlled trial of widely used mood stabilizers demonstrates efficacy in pediatric bipolar disorder. http://www.cincinnatichildrens.org/news/release/2007/kowatch-mood-stabilizer-study/. 
  11. Findling RL et al. Acute treatment of pediatric bipolar I disorder, manic or mixed episode, with aripiprazole: a randomized, double-blind, placebo-controlled study.  J Clin Psychiatry. 2009;70(10):1441-51.
  12. Thomas T et al. Psychopharmacology of pediatric bipolar disorders in children and adolescents. Pediatr Clin N Am. 2011;58:173-97.
  13. Tohen M et al. Olanzapine versus placebo in the treatment of adolescents with bipolar mania.  Am J Psychiatry. 2007;164(10):1547-56
  14. DelBello Mpet al. A double-blind randomized pilot study comparing quetiapine and divalproex for adolescent mania.  J Am Acad Child Adolesc Psychiatry. 2006;45(3):305-13.
  15. Haas M et al. Risperidone for the treatment of acute mania in children and adolescents with bipolar disorder: a randomized, double-blind, placebo-controlled study. Bipolar Disord. 2009;11(7):687-700.
  16. Chen H et al. Comparative effectiveness of monotherapy with mood stabilizers versus second generation (atypical) antipsychotics for the treatment of bipolar disorder in children and adolescents.  Pharmacoepidemiol Drug Saf. 2014;23(3):299-308.
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