Systematic chart review of the pharmacologic treatment of comorbid attention deficit hyperactivity disorder in youth with bipolar disorder

Patterns of comorbidity and dysfunction in clinically referred preschool and school-age children with bipolar disorder

OBJECTIVE

Despite its common onset in preschool years, few studies have examined the characteristics of bipolar disorder (BPD) in preschoolers. This study reports on the clinical characteristics, psychiatric comorbidity, and functioning of preschoolers identified with BPD who were referred to a pediatric psychiatric clinic.

METHODS

Structured psychiatric interviews assessing lifetime psychopathology by Diagnostic and Statistical Manual of Mental Disorders (third edition, revised) criteria were completed with parents about their children and confirmed by clinical interview of the child. Family, social, and overall functioning were also assessed at intake. Findings from preschoolers ages 4 to 6 years were compared with a group of children ages 7 to 9 years (school age).

RESULTS

We identified 44 preschoolers and 29 consecutively ascertained school-age youth with BPD. Preschoolers had similar rates of comorbid psychopathology compared to school-age youth with BPD. Preschoolers and school-age children with BPD typically manifest symptoms of mania and major depression simultaneously (mixed states). Both preschoolers and school-age children had substantial impairment in school, social, and overall functioning.

CONCLUSIONS

These results suggest that clinically referred preschoolers with BPD share with school-age children with BPD high rates of comorbid psychopathology and impaired functioning. Follow-up of these clinically referred preschoolers with BPD evaluating the stability of their diagnoses, treatment response, and their long-term outcome is necessary.

Response to methylphenidate in children with attention deficit hyperactivity disorder and manic symptoms in the multimodal treatment study of children with attention deficit hyperactivity disorder titration trial

OBJECTIVE

Recent reports raise concern that children with attention deficit hyperactivity disorder (ADHD) and some manic symptoms may worsen with stimulant treatment. This study examines the response to methylphenidate in such children.

METHODS

Data from children participating in the 1-month methylphenidate titration trial of the Multimodal Treatment Study of Children with ADHD were reanalyzed by dividing the sample into children with and without some manic symptoms. Two "mania proxies" were constructed using items from the Diagnostic Interview Schedule for Children (DISC) or the Child Behavior Checklist (CBCL). Treatment response and side effects are compared between participants with and without proxies.

RESULTS

Thirty-two (11%) and 29 (10%) participants fulfilled criteria for the CBCL mania proxy and DISC mania proxy, respectively. Presence or absence of either proxy did not predict a greater or lesser response or side effects.

CONCLUSION

Findings suggest that children with ADHD and manic symptoms respond robustly to methylphenidate during the first month of treatment and that these children are not more likely to have an adverse response to methylphenidate. Further research is needed to explore how such children will respond during long-term treatment. Clinicians should not a priori avoid stimulants in children with ADHD and some manic symptoms.

Assessment and treatment of attention deficit hyperactivity disorder in children with comorbid psychiatric illness

PURPOSE OF REVIEW

Attention deficit hyperactivity disorder (ADHD) frequently occurs with a wide variety of comorbid psychiatric disorders such as conduct disorder, depression, mania, anxiety, and learning disabilities. Because the vast majority of children with ADHD are treated in primary care settings, it is important that primary medical doctors be proficient in the diagnosis and initial treatment of children with ADHD and its commonly occurring comorbid disorders. ADHD research is beginning to focus on the treatment of these comorbidly ill children. This review will summarize the recent findings from the psychiatric literature in an attempt to provide the clinician with some initial diagnostic and treatment guidelines for ADHD and its comorbidities.

RECENT FINDINGS

The NIMH Multimodal Treatment Study of ADHD found that children with other disruptive behavior disorders plus ADHD respond well to stimulant medications, with behavioral interventions reducing academic and social impairment. Children with anxiety and ADHD are very responsive across multiple dimensions to behavioral and pharmacological ADHD treatments. Much less is known about the impact of depression on ADHD, and significant debate exists surrounding the identification and treatment of bipolar disorder in children with ADHD. Children with learning disabilities respond well to stimulants but often require additional educational supports. New findings suggest that treating ADHD may prevent the development of future psychiatric disorders.

SUMMARY

The presence of comorbid illness is associated with significant additional morbidity and complicates the diagnosis, treatment, and prognosis of ADHD. Therefore, it is important to identify and treat any comorbid psychiatric conditions in a child with ADHD.

An open trial of bupropion for the treatment of adults with attention-deficit/hyperactivity disorder and bipolar disorder

BACKGROUND

Despite the increasing recognition of comorbid attention-deficit/hyperactivity disorder (ADHD) and bipolar disorder (BPD) in adults, there are no prospective trials of pharmacological agents to treat ADHD in these patients. Given the efficacy of bupropion for ADHD in adults, as well as its use in the management of bipolar depression, we studied the tolerability and efficacy of sustained-release (SR) bupropion in adults with ADHD plus BPD.

METHODS

This was an open, prospective, 6-week trial of bupropion SR (up to 200 mg b.i.d.) in adults with DSM-IV ADHD plus historical bipolar I disorder (BPD I) (10%) or bipolar II disorder (BPD II) (90%). Adults receiving adjunct antimanic agents (mood stabilizers and antipsychotics) at baseline were included in the study. We used standardized psychiatric instruments for diagnosis and outcome. Efficacy was based primarily on the Clinical Global Impression Scale (CGI) for ADHD and the ADHD symptom checklist.

RESULTS

Of 36 patients entered (75% male, mean age 34 years), 30 patients (83%) completed the protocol. At end point (last observation carried forward [LOCF]) compared to baseline, treatment with bupropion SR resulted in significant reductions in the ADHD symptom checklist (-55%, z = 5.63, p <.001) and CGI severity of ADHD (-40%, z = 6.285, p <.001). Bupropion was associated with reductions in ratings of mania and depression.

CONCLUSIONS

The results from this open study of adults with ADHD plus BPD suggest that sustained-release bupropion may be effective in treating ADHD in the context of a lifetime diagnosis of BPD, without significant activation of mania. Further controlled trials are warranted.

A preliminary meta-analysis of the child behavior checklist in pediatric bipolar disorder

BACKGROUND

A possible explanation for the ongoing controversy surrounding pediatric bipolar disorder is that differences in assessment methodologies lead to conflicting results. One way to address methodological differences in assessment across studies is to use a single standardized assessment of psychopathology to calibrate the findings reported in different studies. To this end, we conducted a meta-analysis of several studies that have employed the Child Behavior Checklist in the assessment of children with a diagnosis of bipolar disorder.

METHODS

MEDLINE was searched for all publications that utilized the Child Behavior Checklist in addition to structured diagnostic interviews to assess pediatric bipolar disorder. Random effects models were used to calculate combined estimates of Child Behavior Checklist clinical subscales.

RESULTS

Children with bipolar disorder had scaled scores of >70 in the Aggression, Attention Problems, and Anxious/Depressed subscales of the Child Behavior Checklist. The Child Behavior Checklist was useful in distinguishing bipolar from attention-deficit/hyperactivity disorder subjects.

CONCLUSIONS

While there was a significant heterogeneity in estimates between studies, a consistent pattern of elevations in inattention/hyperactivity, depression/anxiety, and aggression was identified.

Combination pharmacotherapy in children and adolescents with bipolar disorder

BACKGROUND

The purpose of this study was to develop prospective data on the effectiveness of combination pharmacotherapy of children and adolescents with bipolar disorder during a 6-month period of prospective, semi-naturalistic treatment.

METHODS

Thirty-five subjects, with a mean age of 11 years, were treated in the extension phase of this study after having received 6-8 weeks of acute treatment with a single mood stabilizer. The extension phase of this study lasted for another 16 weeks, for a total of 24 weeks of prospective treatment. During this study phase, subjects were openly treated, and they could have their acute-phase mood stabilizer switched or augmented with another mood stabilizer, a stimulant, an antidepressant agent, or antipsychotic agent, if they were assessed to be a nonresponder to monotherapy with their initial mood stabilizer.

RESULTS

During the extension phase of treatment, 20 of 35 subjects (58%) required treatment with one or two mood stabilizers and either a stimulant, an atypical antipsychotic agent, or an antidepressant agent. The response rate to combination therapy was very good, with 80% of subjects treated responding to combination therapy with two mood stabilizers after not responding to monotherapy with a mood stabilizer.

CONCLUSIONS

This study suggests that children and adolescents with bipolar disorder are similar to adults with bipolar disorder, who also frequently require combination therapy.

Non-stimulant treatment for Attention-Deficit/Hyperactivity Disorder

A variety of compounds with a common noradrenergic/dopaminergic activity have shown documented anti-Attention-Deficit/Hyperactivity Disorder (ADHD) activity. There is a substantial body of literature documenting the efficacy of tricyclic antidepressants on ADHD in over 1,000 subjects. There is an equally large database on the efficacy of the specific norepinephrlne reuptake inhibitor, atomoxetine, of greater than 2,000 Individuals. In addition, the atypical antidepressant buproplon also has been documented to be effective in the treatment of ADHD in controlled clinical trials. Despite wide use, the scientific base supporting the efficacy of alpha-2, noradrenergic agonists is somewhat limited. Several lines of evidence provide preliminary support for the potential benefits of cholinergic cognitive enhandng drugs, such as anticholinesterase inhibitors (tacrine, donepezil) as well as novel nicotinic analogues (ABT-418). Despite these promising results, more research is needed on alternative pharmacological treatments for the treatment of ADHD.

Development and natural history of mood disorders

To expand and accelerate research on mood disorders, the National Institute of Mental Health (NIMH) developed a project to formulate a strategic research plan for mood disorder research. One of the areas selected for review concerns the development and natural history of these disorders. The NIMH convened a multidisciplinary Workgroup of scientists to review the field and the NIMH portfolio and to generate specific recommendations. To encourage a balanced and creative set of proposals, experts were included within and outside this area of research, as well as public stakeholders. The Workgroup identified the need for expanded knowledge of mood disorders in children and adolescents, noting important gaps in understanding the onset, course, and recurrence of early-onset unipolar and bipolar disorder. Recommendations included the need for a multidisciplinary research initiative on the pathogenesis of unipolar depression encompassing genetic and environmental risk and protective factors. Specifically, we encourage the NIMH to convene a panel of experts and advocates to review the findings concerning children at high risk for unipolar depression. Joint analyses of existing data sets should examine specific risk factors to refine models of pathogenesis in preparation for the next era of multidisciplinary research. Other priority areas include the need to assess the long-term impact of successful treatment of juvenile depression and known precursors of depression, in particular, childhood anxiety disorders. Expanded knowledge of pediatric-onset bipolar disorder was identified as a particularly pressing issue because of the severity of the disorder, the controversies surrounding its diagnosis and treatment, and the possibility that widespread use of psychotropic medications in vulnerable children may precipitate the condition. The Workgroup recommends that the NIMH establish a collaborative multisite multidisciplinary Network of Research Programs on Pediatric-Onset Bipolar Disorder to achieve a better understanding of its causes, course, treatment, and prevention. The NIMH should develop a capacity-building plan to ensure the availability of trained investigators in the child and adolescent field. Mood disorders are among the most prevalent, recurrent, and disabling of all illnesses. They are often disorders of early onset. Although the NIMH has made important strides in mood disorders research, more data, beginning with at-risk infants, children, and adolescents, are needed concerning the etiology and developmental course of these disorders. A diverse program of multidisciplinary research is recommended to reduce the burden on children and families affected with these conditions.

Attention deficit/hyperactivity disorder across the lifespan

Attention deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder presenting for treatment in youth. ADHD is often chronic with prominent symptoms and impairment spanning into adulthood. ADHD is often associated with co-occurring anxiety, mood, and disruptive disorders, as well as substance abuse. The diagnosis of ADHD by careful review of symptoms and impairment is both reliable and valid. Recent genetic, imaging, neurochemistry, and neuropsychological data support the biological underpinning of the disorder. All aspects of an individual's life must be considered in the diagnosis and treatment of ADHD. Pharmacotherapy, including stimulants, antidepressants, and antihypertensives, plays a fundamental role in the management of ADHD across the lifespan.

Pediatric bipolar mood disorder

The diagnosis of bipolar mood disorder (BP) in preadolescents (pediatric mania) has generated considerable controversy in terms of its estimated prevalence and validity as a diagnostic category. The relative paucity of systematic studies and the current diagnostic confusion related to the disorder are often attributed to the apparent discontinuities in the childhood versus adult presentation of the illness, namely, irritability as the predominant "mood" of mania and a continuous course of symptoms. The goal of this article is to review the current literature and identify sources of confusion relating to pediatric mania by considering results to date within a larger context that include findings from studies on (1) BP illness in adults, (2) mood disorders across the lifespan, (3) the role of development in symptom expression, and (4) patterns of heritability in psychiatric disorders. Whereas much remains to be investigated in the validation of the diagnosis for children, integrating results across studies may provide a framework for understanding the differences in the presentation of severe mood disorders in children and adults.

National Institute of Mental Health research roundtable on prepubertal bipolar disorder

OBJECTIVE

A research roundtable meeting was convened at the National Institute of Mental Health on April 27, 2000, to discuss the existing controversial areas in the diagnosis of bipolar disorder in prepubertal children.

METHOD

Invited clinicians and researchers with expertise on bipolar disorder in children were asked to share and discuss their perspectives on diagnostic issues for bipolar disorder in prepubertal children.

RESULTS

The group reached agreement that diagnosis of bipolar disorder in prepubertal children is possible with currently available psychiatric assessment instruments. In addition to phenotypes that fit DSM-IV criteria for bipolar I and bipolar II, participants agreed on the existence of other phenotypic possibilities that do not meet diagnostic criteria. Bipolar not otherwise specified (NOS) was recommended as a "working diagnosis" for the non-DSM-IV phenotype.

CONCLUSIONS

Bipolar disorder exists and can be diagnosed in prepubertal children. In children who present with both the DSM-lV and non-DSM-IV phenotypes (i.e., those given a diagnosis of bipolar-NOS), assessment should include careful evaluation of all behaviors that are impairing. Moreover, these children should be monitored systematically to explore stability and change over time in diagnosis and impairment.

Parsing pediatric bipolar disorder from its associated comorbidity with the disruptive behavior disorders

The unique pattern of comorbidity found in pediatric mania greatly complicates accurate diagnosis, the course of the disorder, and its treatment. The pattern of comorbidity is unique by adult standards, especially its overlap with attention-deficit/hyperactivity disorder (ADHD), aggression, and conduct disorder. Clinically, symptoms of mania have been discounted as severe ADHD or ignored in the context of aggressive conduct disorder. This atypicality may lead to neglect of the mood component. The addition of high rates of additional disorders contributes to the severe morbidity, dysfunction, and incapacitation frequently observed in these children. A comprehensive approach to diagnostic evaluation is the keystone to establishing an effective treatment program because response to treatment differs with individual disorders. Recognition of the multiplicity of disorders guides therapeutic options in these often refractory conditions. What was previously considered refractory ADHD, oppositionality, aggression, and conduct disorder may respond after mood stabilization. We review these issues in this article.

Special issues in the treatment of paediatric bipolar disorder

Paediatric bipolar disorder (PBD) is an increasingly diagnosed disorder affecting an estimated 1% of children and adolescents. Pharmacological treatment studies in PBD have lagged far behind those in adults. Children are currently treated with pharmacological agents, most of which have proven efficacy in adults. However, PBD is distinct from adult forms of bipolar disorder (BD) and may present unique treatment challenges. PBD often presents with rapid cycling and mixed manic states and a high co-morbidity with behavioural and attention disorders. Early onset depression may also be an early sign of PBD. Due to developmental considerations, the diagnosis of BD may be difficult to make in children without semi-structured interviews. This report discusses the special issues that should be considered when treating PBD and reviews the current literature regarding pharmacotherapy of this population. Mood stabilisers have been studied mostly in an open, uncontrolled fashion but there is growing evidence that lithium, divalproex and carbamazepine are effective in treating PBD. More recent treatment options include atypical antipsychotics and newer anticonvulsants. Other novel agents are currently being investigated in adult BD and may prove applicable to the paediatric form. Finally, based on the available data, a treatment algorithm for PBD is proposed.

Non-stimulant treatments for ADHD

We reviewed the literature of medication trials in ADHD to evaluate the scope of the available non-stimulant treatments. A variety of compounds with a common noradrenergic/ dopaminergic activity have shown documented anti-ADHD activity. There is a substantial body of literature documenting the efficacy of tricyclic antidepressants on ADHD in over 1,000 subjects. In addition, the atypical antidepressant bupropion and the novel noradrenergic specific antidepressant tomoxetine have also been documented to be effective in the treatment of ADHD in controlled clinical trials. Despite wide use, the scientific base supporting the efficacy of alpha-2, noradrenergic agonists continues to be limited. Several lines of evidence provide preliminary support for the potential benefits of cholinergic cognitive enhancing drugs in such as anticholinesterase inhibitors (tacrine, donepezil) as well as novel nicotinic analogues (ABT-418). Despite these promising results, more research is needed on alternative pharmacologic treatments for the treatment of ADHD.

Current research highlights in child and adolescent psychopharmacology

Recent efforts to stimulate research in pediatric psychopharmacology have resulted in increased interest in the effects of psychotropic medications in children and adolescents. This interest is reflected in the number of studies that have been reported or initiated during the past year. As a means of providing a brief update on the progress of child psychopharmacology, research reports either published or presented at national meetings in 1999 are selectively reviewed here. Relevant initiatives recently started under the sponsorship of the National Institute of Mental Health (NIMH) are also reviewed. Most studies have been directed at testing treatments of attention deficit hyperactivity disorder (ADHD), but also studies of the selective serotonin reuptake inhibitors in patients with obsessive compulsive disorder, depression, and anxiety disorders are well represented. The efforts of NIMH to focus on effectiveness research and direct comparisons of pharmacologic, psychosocial, and combined treatment modalities are apparent in recent initiatives in ADHD and depression. Research of treatments for youths with bipolar disorder, schizophrenia, autism, and eating disorders is still scanty and in urgent need of expansion.