The Child Mania Rating Scale-Parent version (CMRS-P) is the first rating scale designed and tested specifically to screen for PBD (Pavuluri et al., 2004b). It has 21 developmentally specific items corresponding to DSM-IV-TR symptoms. A score of >15 (out of 63) indicates a 92% chance of having the diagnosis. However, it is not a diagnostic tool.
Principles of Medication Algorithm
Basic principles of this algorithm model consist of prescription hygiene, mood stabilization, addressing breakthrough symptoms and problem solving.
Prescription hygiene. In establishing a pharmacotherapeutic plan for mood stabilization, four things are important to consider. First, a history should be obtained. Second, rapidly wean off all ineffective medications. Third, discontinue selective serotonin reuptake inhibitors. Despite compelling data in pediatric populations of SSRIs worsening symptoms by either switching to or worsening mania (Biederman et al., 2000), several families bring in children on substantial doses of SSRIs. Fourth, stimulants should be discontinued. However, given the equivocal data (Carlson and Kelly, 1998; Carlson et al., 2000; Scheffer et al., 2005) and the negative influence of stimulants (DelBello et al., 2001; Mota-Castillo et al., 2001; Soutullo et al., 2002), if parents report that stimulants have shown a pattern of response, independent of affect dysregulation, it is advised to continue them but at lowest possible doses and in long-acting form.
Mood stabilization. The first treatment of choice continues to be a mood stabilizer such as lithium (Eskalith, Lithobid) or divalproex (Depakote), due to an established track record mainly based on studies of adult BD. Lithium or divalproex may not always be effective in PBD and/or may slow onset of action. Consequently, second-generation antipsychotics (SGAs) are rapidly finding their place either as monotherapy (in emergencies where stabilizing mania is a priority) (DelBello et al., 2004; Frazier et al., 2001) or in combination with a mood stabilizer (Kowatch et al., 2003; Pavuluri et al., 2004c, 2004d). The SGAs alone may be effective when irritability is prominent and demands a faster response not possible with first-line mood stabilizers (Pavuluri et al., 2004d). Combination therapy of SGAs plus lithium or divalproex is an effective first-line strategy for severe cases, especially those with psychotic features (Kafantaris et al., 2001a, 2001b). This strategy has the advantage of needing lower doses of SGAs compared to doses potentially required for monotherapy, resulting in far less severe adverse events.
In Table 1 and Table 2, we propose a sequence of medication choices in each group and their rationales. While these tables provide a basic guideline, the clinician needs to use their discretion in individual cases. (Prescribing information is summarized in Pavuluri and Janicak [2004]).
Addressing breakthrough symptoms. Pediatric bipolar disorder presents a multitude of clinical challenges beyond acute mood stabilization that must be factored into both the acute and maintenance phases of treatment.
Depression. If there are prominent symptoms of depression, lithium or lamotrigine (Lamictal) are chosen as primary mood stabilizers either alone or as adjuvant to other partially effective agent (Bowden, 2002; Calabrese et al., 2000). The second choice would be a combination of lithium plus lamotrigine. The third choice is a small dose of SSRI (in severe depression). A long-acting medication and psychoeducation are often effective (Wilens et al., 2003). It is important to balance the risks versus benefits, given the "black-box" warning associated with SSRI use in children.
