Bipolar disorder (BD) in children and adolescents is severe and has significant adverse effects on academic, social and family functioning. The high rate of relapse and suicide attempts in youth with BD makes effective treatment essential.
Unfortunately, there are little controlled data available to guide treatment decisions. Most available information is based upon case reports, retrospective studies or open studies. Although mood stabilizers are the mainstay of treatment, there is increasing interest in the newer antipsychotics and anticonvulsant medications for the treatment of this disorder. Before prescribing these medications for children with BD, however, it is important for clinicians to be aware of the existing literature related to the use of these drugs in children and adolescents.
There is only one published double-blind, placebo-controlled study of a mood stabilizer for the treatment of adolescent BD. In this study, 25 adolescent outpatients with diagnoses of BD and substance abuse were randomized to lithium or placebo in a six-week trial. There was significantly greater improvement with lithium than placebo in the treatment of both the BD and the substance dependence. The mean lithium level for responders was 0.9 mEq/L (Geller et al., 1998).
In a multisite study of divalproex (Depakote) treatment in children and adolescents with BD, 48 patients received divalproex until stabilized. Patients then were randomized to either divalproex or placebo. The data are currently being analyzed and should be available shortly (personal communication).
In an open clinical study of valproate treatment for adolescent mania, 15 outpatients received valproate 750 mg/day to 2000 mg/day for seven weeks. Eighty-seven percent of patients showed some symptom improvement (Papatheodorou et al., 1995).
Carbamazepine (Tegretol) up to 300 mg/day has been reported to acutely improve the symptoms of three adolescents with BD. These adolescents received maintenance treatment from two to four years and remained euthymic except for brief episodes of hypomania (Woolston, 1999).
In another recent study, mood stabilizers for treatment in children and adolescents with BD were compared in a six-week open trial. Forty-two outpatient children and adolescents with BD were randomly assigned to lithium (mean serum level 0.9 mEq/L), divalproex (mean serum level 82.8 mcg/L), or carbamazepine (mean serum level 7.1 mcg/L). Response rates defined by 50% reduction in the Young Mania Rating Scale were as follows: divalproex 53%, lithium 38% and carbamazepine 38%. No serious adverse events were found on any mood stabilizer (Kowatch et al., in press).
References
Davanzo PA, Krah N, Kleiner J, McCracken J (1999), Nimodipine treatment of an adolescent with ultradian cycling bipolar affective illness. J Child Adolesc Psychopharmacol 9(1):51-61.
Frazier JA, Meyer MC, Biederman J et al. (1999), Risperidone treatment for juvenile bipolar disorder: a retrospective chart review. J Am Acad Child Adolesc Psychiatry 38(8):960-965.
Geller B, Cooper TB, Sun K et al. (1998), Double-blind and placebo-controlled study of lithium for adolescent bipolar disorders with secondary substance dependency. J Am Acad Child Adolesc Psychiatry 37(2):171-178 [see comments].
Kowatch RA, Suppes T, Carmody TJ et al. (in press), Effect size of lithium, divalproex sodium and carbamazepine in children and adolescents with bipolar disorder. J Am Acad Child Adolesc Psychiatry.
Papatheodorou G, Kutcher SP, Katic M, Szalai JP (1995), The efficacy and safety of divalproex sodium in the treatment of acute mania in adolescents and young adults: an open clinical trial. J Clin Psychopharmacol 15(2):110-116.
Ryback RS, Brodsky L, Munasifi F (1997), Gabapentin in bipolar disorder. J Neuropsychiatry Clin Neurosci 9(2):301 [letter].
Soutullo CA, Sorter MT, Foster KD et al. (1999), Olanzapine in the treatment of adolescent acute mania: a report of seven cases. J Affect Disord 53(3):279-283.
Woolston JL (1999), Case study: carbamazepine treatment of juvenile-onset bipolar disorder. J Am Acad Child Adolesc Psychiatry 38(3):335-338.
