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Maintenance and Long-Term Treatment Issues in Special Populations: BD and Dementia: Page 3 of 10

Maintenance and Long-Term Treatment Issues in Special Populations: BD and Dementia: Page 3 of 10

There are conflicting data regarding gender differences in rates of long-term medication adherence in BD (Colom and Vieta, 2002). However, one early study of nonadherence found that women more than men were prone to missing their high periods and to feel bothered by the idea of their moods being "controlled" by medication (Jamison et al., 1979). These concerns--in addition to the not unrealistic fear of weight gain--may pose significant challenges in the long-term treatment of women with BD.

The take-home message regarding women with BD. Thyroid disease, premenstrual exacerbation of bipolar symptoms, teratogenic effects of medications used during pregnancy, postpartum psychosis and neonatal toxicity from the use of medications while breast-feeding are all potential complications in females with BD. Long-term treatment in this population entails a careful risk-benefit assessment of these issues, as well as close cooperation between psychiatrists, obstetricians and other physicians. Compared with divalproex or carbamazepine, lithium may be the safest mood stabilizer to use during pregnancy, notwithstanding some risk of cardiac malformations with first-trimester lithium use. Asking about missing their high periods or feeling "controlled" by medication may help improve medication adherence among female patients with BD. Helping the patient reduce medication-related weight gain may also improve compliance.

Children and adolescents. The prevalence of BD in younger populations remains a matter of some controversy; however, prevalence rates may be as high as 5% when including subsyndromal forms of the illness (Wolf and Wagner, 2003). Bipolar disorder in younger cohorts may be difficult to diagnose, owing to the presence of comorbid conditions (e.g., attention-deficit/hyperactivity disorder) and mixed features of mania and depression. Bipolar disorder beginning in the younger years is associated with chronicity, high severity and disruption of normal psychosocial development (Wolf and Wagner, 2003).

Long-term, controlled studies of treatment in younger populations are generally lacking; hence, treatment decisions are often based on small cases studies and extrapolations from the adult literature. This problem is especially vexing, because many children and adolescents with BD require more than one medication for long-term management (Wagner, 2004; Wolf and Wagner, 2003). A comprehensive review of BD treatment in younger populations is beyond the scope of this paper. Although most information is derived from experience with lithium and divalproex, several reviews cite evidence favoring use of lithium, divalproex, carbamazepine and several atypical antipsychotics, including olanzapine (Zyprexa), risperidone (Risperdal) and quetiapine (Seroquel) (Wagner, 2004; Wolf and Wagner, 2003). Unfortunately, few of the studies cited used long-term, randomized, placebo-controlled designs. Most were small, uncontrolled or involved more than one medication. Indeed, Wolf and Wagner (2003) concluded:

 

Controlled research is needed to identify efficacious treatment for bipolar disorder in children and adolescents and to establish optimal treatment duration. It is important to determine whether early treatment intervention affects the course of the illness and reduces the likelihood of its occurrence in adulthood.

Current American Psychiatric Association guidelines recommend that treatment with a maintenance agent should continue for at least 18 months after stabilization of a manic episode in adolescents and children with BD (Hirschfeld et al., 2002). Full stabilization may require several years of treatment. Unfortunately, currently available treatments are associated with numerous side effects in younger patients with BD, including gastrointestinal symptoms, weight gain, neurotoxicity, hyperprolactinemia, sedation, acne and alopecia. Furthermore, Colom and Vieta (2002) suggested that younger patients with BD may be at particularly high risk for noncompliance with maintenance treatment. Thus, long-term treatment of younger patients with BD must constantly monitor for both adverse effects of and adherence to pharmacotherapy. Psychosocial support, including involvement with support groups for adolescent BD, is often critical in maintaining the younger patient in treatment.

The take-home message regarding children and BD. Diagnosis and treatment of younger patients with BD requires careful evaluation for the presence of mixed features as well as comorbid disorders such as ADHD. Lithium, divalproex, carbamazepine and atypical antipsychotics appear to be useful in younger patients with BD, but long-term, controlled data are lacking. Nevertheless, expert guidelines indicate that maintenance agents should be continued for at least 18 months after stabilization of a manic episode in adolescents and children with BD. Clinicians need to monitor these children and adolescents carefully for such side effects as weight gain, endocrine abnormalities and neurotoxicity. Because younger patients with BD are at high risk for noncompliance with maintenance treatment, careful assessment, education and support are required to enhance adherence to treatment. Disruption of normal adolescent psychosocial development as a result of BD may require counseling and peer group support.

Elderly patients with BD. Some data indicate that about 10% of all patients with BD are age 50 or older and that BD accounts for 5% to 19% of mood disorders in the elderly (Manisses Communications Group, Inc., 2002; Sajatovic, 2002). However, a clear picture of the prevalence of BD among the elderly is lacking, owing to under-use of the mental health system by this population. Furthermore, new manic episodes in the elderly may not represent true BD as defined by DSM-IV, but rather, secondary manifestations of thalamic infarction, white matter changes, general medical conditions, prescribed medications or substance use (Ghaemi, 2003; Hirschfeld et al., 2002).

 
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