Guidelines now available for pediatric bipolar disorder

The best treatment for young patients with bipolar disorder (BPD) has been elusive. Confounding factors include few large-scale studies, differences between adult and childhood BPD, and a lack of useful treatment guidelines.

A work group of 20 pediatric psychiatry experts and members of the Child & Adolescent Bipolar Foundation sat down recently to develop consensus guidelines. They developed two algorithms that outline suggested strategies for treatment of acute BPD-1 (manic or mixed) for children with and without psychosis.

Monotherapy with a traditional mood stabilizer (lithium, divalproex, or carbamazepine) or an atypical antipsychotic (olanzapine, quetiapine, or risperidone) is considered first line of treatment for children with acute BPD-1 without psychosis. While the panel could make no definitive recommendation as to an initial selection, due to a lack of comparative efficacy data, the majority preferred lithium or divalproex as the first drug choice for nonpsychotic mania.

Patients showing either no improvement or intolerable side effects after initial monotherapy, and those with no positive response to an augmenting agent, should then receive monotherapy with a medication not used in stage 1. The six-stage algorithm progresses with increases to two- and three-drug combinations (stages 3 and 4); trials with alternate monotherapy with oxcarbazepine, ziprasidone, or aripiprazole (stage 5); and finally clozapine (stage 6) in children with no response to earlier treatment.

An algorithm for patients with psychosis recommended initial treatment with a mood stabilizer plus an atypical antipsychotic. If no response is seen, a triple-combination treatment, such as with lithium, divalproex, and an atypical antipsychotic, is recommended.

"Psychosis and severe aggression increase treatment urgency and complexity," said Gabrielle A. Carlson, M.D., director of child and adolescent psychiatry at Stony Brook University School of Medicine and a work group member. Before second-generation antipsychotics were available, clinicians were loath to use medications like haloperidol and fluphenazine in patients without psychosis. Now, she said, the newer antipsychotics, which also act as mood stabilizers and anti-aggression medications, are used for acute mania regardless of psychosis.

Due to insufficient data, the authors were unable to develop an algorithm for treating bipolar depression in children. But based on data in adults, the group recommends lithium as a treatment option in this population. One study cited in the guidelines showed that using selective serotonin reuptake inhibitors (SSRIs) improved bipolar depressive symptoms. However, the drugs had destabilizing effects in some of the children. The group recommended SSRI and bupropion use only as adjunctive treatments after a mood stabilizer is in place, and treatment with antidepressants should be continued for at least eight weeks after there is depressive symptom remission.

Although the guidelines mention lamotrigine as a treatment alternative for bipolar depression in children based on retrospective analysis and clinical experience, Paul J. Perry, Ph.D., professor of psychiatry and pharmacy, University of Iowa, disagrees. Using lamotrigine for maintenance treatment in kids risks Stevens-Johnson syndrome, he said. Perry prefers the use of lithium plus an SSRI, but admitted that this combination is not based on any randomized, controlled data. Once a patient is stabilized, maintenance treatment should continue for at least 12 to 14 consecutive months after remission, according to the guidelines, with possibly a briefer treatment period for less severely ill patients. After that, the panel recommends medication tapering or discontinuation. Stopping treatment may be more risky for patients with a history of suicidal behavior, severe aggression, and/or psychosis.

Perry suggests that parents of children with comorbid psychiatric disorders, such as attention-deficit hyperactivity disorder, oppositional defiant-, conduct-, or anxiety disorder, find a child psychiatrist diagnostician who can treat the illnesses one at a time. The panel recommends stabilization of the symptoms of BPD first, followed by treatment of the coexisting conditions.