Double-blind and placebo-controlled study of lithium for adolescent bipolar disorders with secondary substance dependency

Reliability of the Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS) mania and rapid cycling sections

OBJECTIVE

To investigate the reliability of the Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS) mania and rapid cycling sections.

METHOD

The 1986 version of the KSADS was modified and expanded to include onset and offset of each symptom for both current and lifetime episodes, expanded prepubertal mania and rapid cycling sections, and categories for attention-deficit/hyperactivity disorder and other DSM-IV diagnoses. To optimize diagnostic research, skip-outs were minimized. Subjects participated in the ongoing "Phenomenology and Course of Pediatric Bipolar Disorder" study. Mothers and children were interviewed separately by research nurses who were blind to diagnostic group status. In addition, ratings of off-site child psychiatrists, made from the narrative documentation given for each WASH-U-KSADS item, were compared with research nurse ratings. This work was performed between 1995 and 2000.

RESULTS

There was 100% interrater reliability, five consecutive times, as both interviewer and observer after 10 to 15 trials. The kappa values of comparisons between research nurse and off-site blind best-estimate ratings of mania and rapid cycling sections were excellent (0.74-1.00). High 6-month stability for mania diagnoses (85.7%) and for individual mania items and validity against parental and teacher reports were previously reported.

CONCLUSIONS

The WASH-U-KSADS mania and rapid cycling sections have acceptable reliability.

Bipolar disorder with comorbid substance abuse: diagnosis, prognosis, and treatment

Alcohol and drug abuse occur frequently in individuals with bipolar disorder, but clinicians may often feel ill-prepared to identify such multi-diagnosis syndromes, to contextualize drug abuse alongside affective symptoms, and to formulate appropriate treatment strategies. Plausible explanations for high comorbidity rates between bipolar illness and substance use disorders are complex and likely embrace numerous factors that extend beyond simple, older theories about drug use as sheer "self-medication." Evidence from epidemiologic, family-genetic, pharmacologic, psychosocial, and clinical psychopathology studies suggest that a majority of bipolar patients are at risk for developing lifetime drug or alcohol-related problems, which may in turn contribute to more varied and complex clinical presentations, accelerated relapses, worsening of depressive features, poorer lithium response, functional disability, and elevated suicide risk. In this article, the author reviews essential concepts about the phenomenology and treatment outcome of bipolar illness with substance use comorbidities and offers a systematic approach to the diagnosis and management of patients with such dual diagnoses.

Psychosocial functioning in a prepubertal and early adolescent bipolar disorder phenotype

OBJECTIVE

To compare psychosocial functioning (PF) in a prepubertal and early adolescent bipolar disorder phenotype (PEA-BP) sample to two comparison groups, i.e., attention-deficit/hyperactivity disorder (ADHD) and community controls (CC).

METHOD

There were 93 PEA-BP (with or without comorbid ADHD), 81 ADHD, and 94 CC subjects who were participants in an ongoing study, the Phenomenology and Course of Pediatric Bipolar Disorders. Cases in the PEA-BP and ADHD groups were outpatients obtained by consecutive new case ascertainment, and CC subjects were from a survey conducted by the Research Triangle Institute. To fit the study phenotype, PEA-BP subjects needed to have current DSM-IV mania or hypomania with elation and/or grandiosity as one criterion. Assessments for PF were by experienced research nurses who were blind to group status. Mothers and children were separately interviewed with the Psychosocial Schedule for School Age Children-Revised.

RESULTS

Compared with both ADHD and CC subjects, PEA-BP cases had significantly greater impairment on items that assessed maternal-child warmth, maternal-child and paternal-child tension, and peer relationships.

CONCLUSIONS

Clinicians need to consider PF deficits when planning interventions. In the PEA-BP group, there was a 43% rate of hypersexuality with a <1% rate of sexual abuse, supporting hypersexuality as a manifestation of child mania.

Parsing the association between bipolar, conduct, and substance use disorders: a familial risk analysis

BACKGROUND

Bipolar disorder has emerged as a risk factor for substance use disorders (alcohol or drug abuse or dependence) in youth; however, the association between bipolar disorder and substance use disorders is complicated by comorbidity with conduct disorder. We used familial risk analysis to disentangle the association between the three disorders.

METHODS

We compared relatives of four proband groups: 1) conduct disorder + bipolar disorder, 2) bipolar disorder without conduct disorder, 3) conduct disorder without bipolar disorder, and 4) control subjects without bipolar disorder or conduct disorder. All subjects were evaluated with structured diagnostic interviews. For the analysis of substance use disorders, Cox proportional hazard survival models were utilized to compare age-at-onset distributions.

RESULTS

Bipolar disorder in probands was a risk factor for both drug and alcohol addiction in relatives, independent of conduct disorder in probands, which was a risk factor for alcohol dependence in relatives independent of bipolar disorder in probands, but not for drug dependence. The effects of bipolar disorder and conduct disorder in probands combined additively to predict the risk for substance use disorders in relatives.

CONCLUSIONS

The combination of conduct disorder + bipolar disorder in youth predicts especially high rates of substance use disorders in relatives. These findings support previous results documenting that when bipolar disorder and conduct disorder occur comorbidly, both are validly diagnosed disorders.

Implications of genetic epidemiology for the prevention of substance use disorders

Despite advances in characterizing human genotypes, the complex process through which genes exert their influence limits the application of molecular genetics to human diseases. Substance use disorders are necessarily complicated by gene-environment interaction because exposure to an exogenous substance is required for their development. The methods of genetic epidemiology are specifically designed to identify sources of complexity that impede etiologic findings and prevention efforts. The goal of this paper is to illustrate the application of family study methods to identify risk factors for substance abuse and their implications for prevention. The Yale Family Study is a controlled family study of the comorbidity of substance and psychiatric disorders. The sample consists of 223 probands with substance use and/or an anxiety disorders and community controls, 1218 adult first degree relatives and spouses, and 203 offspring (ages 7-17) followed for 8 years. Results indicated familial aggregation of substance disorders in adults and children, independence of familial aggregation of alcoholism and drug dependence, and specificity of familial clustering of some drugs of abuse. Familial factors are more strongly associated with substance dependence than abuse, with an attributable risk of 55%. Premorbid psychiatric disorders--social phobia and bipolar affective disorder in adults, and depression, anxiety, conduct, and oppositional defiant disorders in children--were strongly associated with the subsequent development of substance dependence (attributable risks ranging from 44 to 86%). A family history of substance abuse and premorbid psychopathology are strongly associated with the development of substance use disorders. Implications for primary and secondary prevention are discussed. As specific genetic vulnerability markers for substance use disorders become identified, application of the tools of genetic epidemiology may be employed to identify specific environmental risk factors that may serve as targets for prevention.

Acute and continuation pharmacological treatment of children and adolescents with bipolar disorders; a summary of two previous studies

We report the results of an acute-phase and continuation-phase study of the pharmacological treatment of children and adolescents with bipolar disorders. The acute phase study, with a duration of 6-8 weeks, aimed at developing effect sizes (ES) for lithium, divalproex sodium, and carbamazepine, in the acute phase treatment of Bipolar I or II children and adolescents during a mixed or manic episode. During the acute-phase of treatment, 42 outpatients with a mean age of 11.4 yr. (20 with Bipolar I Disorder and 22 with Bipolar II Disorder) were randomly assigned to 6-8 weeks of open treatment with either lithium, divalproex sodium, or carbamazepine. The primary efficacy measures were the weekly CGI Improvement scores and the Young Mania Rating Scale. Using a ≥ 50% change from baseline to exit in the Y-MRS scores to define response, the effect size for divalproex sodium was 1.63,1.06 for lithium, and 1.00 for carbamazepine. Using this same response measure with the intent-to-treat sample, the response rates were: sodium divalproex 53%; lithium 38%; and carbamazepine 38% (x 2=0.85, 2 d.f., p=0.60). Thirty-five subjects continued in open, treatment for another 16-18 weeks, for a total of 24 weeks of prospective treatment. Overall, of the thirty-five continuation phase subjects, thirty (85%) were categorized as responders at the end of the continuation phase of treatment. Of these thirty-five subjects, 13 (37%) were only on a single mood stabilizer and no other psychotropic agents at the end of the continuation phase. Thirty-one percent of subjects in continuation were also treated with a stimulant medication in addition to mood stabilizers.

Impact of substance abuse on the course and treatment of bipolar disorder

OBJECTIVES

The objectives of this article are to review the prevalence, natural history, pathophysiology, and treatment of comorbid bipolar disorder with alcoholism and other psychoactive substance use disorders (PSUDs).

METHODS

All identified bibliographies through a literature search of all Medline files and bibliographies of selected articles focusing on the prevalence, natural history, course, prognosis, inter-relationship, and treatment of bipolar disorder with comorbid alcoholism and other PSUDs were reviewed.

RESULTS AND CONCLUSIONS

Comorbidity of bipolar disorder and alcoholism and other PSUDs is highly prevalent. The presence of this so called 'dual diagnoses' creates a serious challenge in terms of establishing an accurate diagnosis and providing appropriate treatment interventions. The inter-relationship between these disorders appears to be mutually detrimental. The course, manifestation, and treatment of each condition are significantly compounded by the presence of the other condition. Substance abuse and alcoholism appear to significantly complicate the course and prognosis of bipolar disorder resulting in increased suffering, disability, and costs. On the other hand, bipolar disorder may be a risk factor for developing PSUDs. Although, there are a number of hypotheses explaining the pathophysiological mechanism involved in such comorbidities, our understanding of the exact nature of such neurobiological mechanisms is still limited. While the antikindling agents and targeted psychotherapeutic techniques may be useful intervention strategies, there is still a significant lack of empirically based treatment options for these patients.

The rationale, design, and progress of two novel maintenance treatment studies in pediatric bipolarity

INTRODUCTION

There are no definitively established acute or maintenance treatments for juvenile bipolar disorder.

METHOD

Two randomized, blind, maintenance clinical trials in children and adolescents with bipolar disorders are ongoing at the University Hospitals of Cleveland/Case Western Reserve University Stanley Clinical Research Center for bipolar disorder. The first is comparing the safety and effectiveness of lithium carbonate (Li+) to divalproex sodium (VPA) for up to 76 weeks in youths with stabilized bipolar illness (type 1 or 2). The second study is designed to compare the efficacy of VPA to placebo in the acute management of subsyndromal symptoms of bipolar disorder ('cyclotaxia') and the prevention of the full syndrome in children at risk. Both studies use the prospective life-chart method as an outcome measure.

RESULTS

Sixty-six youths have received study medication as part of the trial that is comparing Li+ to VPA as a maintenance therapy. In addition, 32 youths have received blinded treatment as part of the 'cyclotaxia' prevention study. Combination Li+A/PA treatment appears generally well tolerated and seems to have robust anti-manic and antidepressant effects.

DISCUSSION

Since the blind has not been broken on either of these clinical trials, conclusions about the maintenance effectiveness of either VPA or Li+ in youths with bipolar disorder type 1 or 2 cannot be made yet. Similarly, it is unclear whether VPA is superior to placebo in genetically high-risk youths with cyclotaxia. The final results of these trials should provide valuable information about the treatment of juvenile bipolar disorders.

A double-blind, placebo-controlled trial of sertraline in depressed adolescent alcoholics: a pilot study

In order to preliminarily evaluate the efficacy, safety and tolerability of the serotonin reuptake inhibitor, sertraline, in the treatment of adolescents with a primary depressive disorder and a comorbid alcohol use disorder, a 12-week double-blind, placebo-controlled trial of sertraline plus cognitive behavior group therapy was conducted. Subjects were 10 outpatient treatment-seeking adolescents. Baseline assessment included the K-SADS, HAM-D, SCID, and the Time-Line Follow-Back. The HAM-D and the Time-Line Follow-Back were performed weekly thereafter. Both groups showed a significant reduction in depression scores with an average reduction between baseline and endpoint HAM-D score of -9.8 (F(1,8)=26.14, p</=0.001), although there were no significant group differences. There was an overall reduction in Percent Days Drinking (PDD); (F(1,8)=8.90, p<0.02) and in Drinks Per Drinking Day (DDD); (F(1,8)=20.48, p<0.002), however, there were no group differences. Depression responders tended to have higher baseline PDD than non-responders (F(1,8)=3.9, p=0.08) and change in HAM-D scores tended to correlate with change in PDD (r=0.57, p=0.09). Our data support that sertraline is safe and well tolerated in the treatment of adolescents with depression and alcohol dependence. Small sample size and cognitive behavior group therapy given to all subjects may limit the lack of group differences. Copyright 2000 John Wiley & Sons, Ltd.

Effect size of lithium, divalproex sodium, and carbamazepine in children and adolescents with bipolar disorder

OBJECTIVE

To develop effect sizes for 3 mood stabilizers--lithium, divalproex sodium, and carbamazepine--for the acute-phase treatment of bipolar I or II disorder, mixed or manic episode, in children and adolescents aged 8 to 18 years.

METHOD

Forty-two outpatients with a mean age of 11.4 years (20 with bipolar I disorder and 22 with bipolar II disorder) were randomly assigned to 6 weeks of open treatment with either lithium, divalproex sodium, or carbamazepine. The primary efficacy measures were the weekly Clinical Global Impression Improvement scores and the Young Mania Rating Scale (Y-MRS).

RESULTS

Using a > or = 50% change from baseline to exit in the Y-MRS scores to define response, the effect size was 1.63 for divalproex sodium, 1.06 for lithium, and 1.00 for carbamazepine. Using this same response measure with the intent-to-treat sample, the response rates were as follows: sodium divalproex, 53%; lithium, 38%; and carbamazepine, 38% (chi 2(2) = 0.85, p = .60). All 3 mood stabilizers were well tolerated, and no serious adverse effects were seen.

CONCLUSIONS

Divalproex sodium, lithium, and carbamazepine all showed a large effect size in the open treatment of children and adolescents with bipolar I or II disorder in a mixed or manic episode.

One-year outcome of adolescent females referred for conduct disorder and substance abuse/dependence

We investigated whether substance abuse/dependence, conduct disorder, and other psychiatric disorders improved in adolescent females who were referred to outpatient treatment and which variables were related to 1-year outcome. Forty-six out of 60 conduct-disordered (CD) adolescent females with substance abuse or dependence were re-evaluated approximately 1 year after discharge. Treatment length averaged 16 weeks. Significant improvements were seen in three areas: (1) criminality and CD; (2) attention deficit hyperactivity disorder (ADHD); and (3) educational and vocational status. However, neither substance involvement nor depression improved, regardless of length of stay in treatment, and these females demonstrated significant risky sexual behaviors. In contrast to our previous work with adolescent males (Crowley, T.J., Mikulich, S.K., Macdonald, M., Young, S.E., Zerbe, G.O., 1998. Substance-dependent, conduct-disordered adolescent males: severity of diagnosis predicts 2-year outcome. Drug Alcohol Depend. 49, 225-237), we were not able to identify pre-intake variables, other than performance IQ, that were related to substance use and conduct outcomes. Only two post-treatment factors (peer problems and number of ADHD symptoms at follow-up) were found to be related to CD and substance use disorders outcomes. The overall lack of pre- and post-treatment predictors presents interesting challenges for future research on adolescent females with these disorders.

Placebo effect in randomized, controlled maintenance studies of patients with bipolar disorder

The prevention of mood episodes is an important goal of the maintenance treatment of patients with bipolar disorder. The rate of relapse on placebo compared with that on active treatment is an important issue in the design of future clinical trials of maintenance treatment. We examine the range and time course of placebo relapse rates in studies of patients with bipolar I disorder. In addition, we address the potential variables associated with placebo response, strategies to minimize placebo response, the optimum duration of placebo-controlled maintenance trials, possible alternatives to placebo control groups, and the impact of these considerations in maintenance studies of children, adolescents, and older adults with bipolar disorder.

Placebo effect in randomized, controlled studies of acute bipolar mania and depression

Randomized, double-blind, placebo-controlled, parallel group clinical trials have been the standard methodology for establishing the efficacy of new treatments for patients with bipolar disorder in manic, mixed, or depressive episodes. We examine the placebo response rate in acute treatment trials of acute mania (and mixed states) and bipolar depression. Also addressed are potential variables associated with placebo response, strategies to minimize placebo response, the optimum duration of placebo-controlled acute treatment trials, possible alternatives to the use of placebo, and the ramifications of these issues with regard to the design of studies in children, adolescents, and older adults with bipolar disorder.

Bipolar disorder in youth

The debate regarding the possible existence of prepubertal bipolar illness has surfaced at various points in history. In its most recent incarnation, proponents of a childhood bipolar diagnosis argue that there is an early-onset form of bipolar illness that is highly comorbid and characterized by simultaneous irritability and depression. Others have suggested that childhood manic symptoms are more likely a nonspecific indicator of risk, or may be the result of symptom overlap with various other forms of childhood pathology. This article briefly reviews pertinent findings from epidemiologic, developmental, family, and treatment studies that shed light on the etiology, phenomenology, and developmental significance of manic symptoms in young people.

Disruptive behavior disorders and substance use disorders in adolescents

Disruptive behaviors disorders in the form of conduct disorder, oppositional defiant disorder and/or attention-deficit hyperactivity disorder are found in a majority of adolescents with substance use disorders These disorders influence the risk for and the course of substance use disorders in adolescents and potentially provide important targets for intervention. Interventions such as family therapy and multisystemic therapy can focus on important environmental factors that help to produce and sustain substance use, related problems and disruptive/deviant social behavior. Researchers and clinicians are increasingly utilizing multimodal approaches that use several psychosocial approaches in addition to medication, if indicated. This article reviews our current understanding of the relationship between disruptive behavior disorders and substance use disorders in adolescents and the importance of this understanding in the prevention, assessment and treatment of adolescents with substance use disorders.

Effective treatment for mental disorders in children and adolescents

As pressure increases for the demonstration of effective treatment for children with mental disorders, it is essential that the field has an understanding of the evidence base. To address this aim, the authors searched the published literature for effective interventions for children and adolescents and organized this review as follows: (1) prevention; (2) traditional forms of treatment, namely outpatient therapy, partial hospitalization, inpatient treatment, and psychopharmacology; (3) intensive comprehensive community-based interventions including case management, home-based treatment, therapeutic foster care, and therapeutic group homes; (4) crisis and support services; and (5) treatment for two prevalent disorders, major depressive disorder and attention-deficit hyperactivity disorder. Strong evidence was found for the treatment of attention-deficit hyperactivity disorder, depression, anxiety, and disruptive behavior disorders. Guidance from the field relevant to moving the evidence-based interventions into real-world clinical practice and further strengthening the research base will also need to address change in policy and clinical training.

Bipolarity in children

Childhood and adolescent bipolar disorder have been less studied than adult onset bipolar illness. However, case reports of mania in childhood can be found as early as the mid 19th century. Historically, several factors have made the accurate diagnosis of bipolar disorder in childhood difficult: clinical bias against the diagnosis of mania in children; low base rate of disorder; symptom overlap between bipolar disorder and other more prevalent childhood-onset psychiatric disorders; and developmental constraints and variability in clinical presentation. The epidemiology of juvenile-onset bipolar disorder remains an open topic for research. The disorder appears to increase in prevalence with advancing age until young adulthood. Reported phenomenology of bipolar disorder in children and adolescents indicates a highly variable presentation with a developmental trend towards increased resemblance to the adult phenotype with increasing age of onset. Diagnostic accuracy for the disorder is improved by adherence to diagnostic and statistical manual of mental disorders (DSM) criteria and may be aided by structured or semistructured diagnostic interviews. The course of bipolar disorder in children and adolescents has also received limited systematic study. However, research to date supports a clinical picture of a relapsing, recurrent illness with substantial morbidity. Systematic studies of pharmacologic treatments of acute mania in children and adolescents are limited in number and scope. Clinical justification for the use of acute antimanic treatments such as lithium and valproic acid is still based upon studies conducted in adults. There remains an immediate and significant need for additional research into all aspects of juvenile-onset bipolar disorder.

Substance abuse and bipolar comorbidity

Bipolar disorder and substance abuse commonly co-occur. In fact, as many as 50% of individuals with bipolar disorder have been found to have a lifetime history of substance abuse or dependence. This article discusses the very important comorbidity of bipolar disorder as it is complicated by substance abuse, focusing on the prevalence, course, diagnostic considerations and treatment.

Risk for substance use disorders in youths with child- and adolescent-onset bipolar disorder

OBJECTIVE

Previous work in adults has suggested that early-onset bipolar disorder (BPD) is associated with an elevated risk for substance use disorders (SUD). To this end, the authors assessed the risk for SUD in child- versus adolescent-onset BPD with attention to comorbid psychopathology.

METHOD

All youths (aged 13-18 years) with available structured psychiatric interviews were studied systematically. From clinic subjects (N = 333), 86 subjects with DSM-III-R BPD were identified. To evaluate the risk for SUD and BPD while attending to developmental issues, the authors stratified the BPD sample into those with child-onset BPD (< or = 12 years of age, n = 50) and those with adolescent-onset BPD (13-18 years of age, n = 36).

RESULTS

In mid-adolescence, youths with adolescent-onset BPD were at significantly increased risk for SUD relative to those with child-onset BPD (39% versus 8%; p = .001). Compared with those with child-onset BPD, those with adolescent-onset BPD had 8.8 times the risk for SUD (95% confidence interval = 2.2-34.7; chi 7(2) = 9.7, p = .002). The presence of conduct disorder or other comorbid psychopathology within BPD did not account for the risk for SUD.

CONCLUSIONS

Adolescent-onset BPD is associated with a much higher risk for SUD than child-onset BPD, which was not accounted for by conduct disorder or other comorbid psychopathology. Youths with adolescent-onset BPD should be monitored and educated about SUD risk. The identification and treatment of manic symptomatology may offer therapeutic opportunities to decrease the risk for SUD in these high-risk youths.

Mood stabilizers in children and adolescents

OBJECTIVE

The efficacy of mood stabilizers in children and adolescents has not been studied adequately. This article will review existing studies and highlight some important issues in designing future studies on these agents.

METHOD

Electronic databases including Medline, Psycholnfo, and CRISP were searched for data in children receiving compounds that have mood-stabilizing properties in adults.

RESULTS

Some open clinical data and an extremely modest amount of controlled research data suggest lithium, carbamazepine, and valproate may be effective mood stabilizers in children and adolescents. There are no controlled data on other potential mood stabilizers in children.

CONCLUSIONS

The disorders that may be responsive to mood stabilizers are among the most morbid in child psychiatry. More studies are needed to clarify the efficacy of these compounds in children and adolescents and to provide a rational basis for choosing among them.

Prepubertal and early adolescent bipolarity differentiate from ADHD by manic symptoms, grandiose delusions, ultra-rapid or ultradian cycling

BACKGROUND

In contrast to differential diagnosis (ddx) of older adolescent and adult bipolarity (BP), which includes schizophrenia and substance use disorders, the main ddx of prepubertal and early adolescent BP is attention-deficit disorder with hyperactivity (ADHD). To address this ddx issue, and to provide prepubertal mania manifestations, interim baseline data are presented from the National Institute of Mental Health (NIMH)-funded study 'Phenomenology and Course of Pediatric Bipolarity'.

METHODS

Data are from the first 60 BP and the first 60 ADHD cases from 270 consecutively ascertained subjects (90 BP, 90 ADHD and 90 community controls). Comprehensive assessments included the Washington University at St. Louis Kiddie and Young Adult-Schedule for Affective Disorders and Schizophrenia--Lifetime and Present Episode Version-DSM-IV (WASH-U-KSADS) blindly administered by nurses to mothers about their offspring and to children/adolescents about themselves. Caseness was established by consensus conferences that included diagnostic and impairment data, teacher and school reports, agency records, videotapes and medical charts.

RESULTS

Mean baseline age of BP cases was 11.0+/-2.7 years and the mean age at onset of BP was 8.1+/-3.5 years. Elated mood, grandiosity, hypersexuality, decreased need for sleep, racing thoughts and all other mania items except hyperenergetic and distractibility were significantly and substantially more frequent among BP than ADHD cases (e.g., elation: 86.7% BP vs. 5.0% ADHD; grandiosity: 85.0% BP vs. 6.7% ADHD). In the BP group, 55.0% had grandiose delusions, 26.7% had suicidality with plan/intent and 83.3% were rapid, ultra-rapid or ultradian cyclers.

LIMITATIONS

Sites for consecutive case ascertainment from the lowest socioeconomic status classes were unavailable due to current health care policies.

CLINICAL RELEVANCE

Prepubertal and early adolescent BP cases differentiate from ADHD by mania-specific criteria and commonly present with ultra-rapid or ultradian cycling.

Lithium for prepubertal depressed children with family history predictors of future bipolarity: a double-blind, placebo-controlled study

BACKGROUND

Because of negative studies of TCAs for prepubertal major depressive disorder (PMDD) and because of the potentially high switch rate of PMDD to prepubertal bipolarity (BP), it was hypothesized that lithium would be efficacious treatment for PMDD in children who also had family history (FH) predictors of future BP.

METHODS

A double-blind, placebo-controlled, and pharmacokinetically dosed study of lithium for PMDD with FH predictors of future BP was performed. Random assignment was stratified by FH of BP-I or mania versus loaded/multigenerational (L/M) FH of MDD without BP-I or mania. Comprehensive assessments were done during a six week outpatient protocol that included weekly serum lithium levels.

RESULTS

Mean age was 10.7+/-1.2 years; 17 subjects were randomized to active and 13 to placebo; 80% had FH of BP-I or mania (40% of parents had BP-I or mania); and 20% had FH of L/M MDD. Using both intent to treat with last observation carried forward (n = 30) and completer (n = 24) analyses, there were no significant differences on continuous or categorical measures between active and placebo groups. Mean serum lithium level was 0.99+/-0.16 mEq/l. There were no significant differences between mean total daily dose or mean serum lithium levels between responders and non-responders.

LIMITATIONS

Four subjects on active drug were discontinued because of dose-limiting side effects (three were cognitive impairment). Future studies of treatment for PMDD should consider alternative drugs.

CLINICAL RELEVANCE

Lithium was not significantly more efficacious than placebo for PMDD with FH predictors of future BP.

Mood stabilizers and anticonvulsants

This article provides pediatricians and other clinicians who treat children and adolescents with a working knowledge of mood stabilizers and their potential uses in children and adolescents with mood and behavior disorders. Mood stabilizers are ubiquitous agents that are often effective in the treatment of children and adolescents with bipolar disorders or conduct disorders and mentally retarded patients with aggressive behavior. The authors' also discuss mechanisms of action, pharmacokinetics, dosing, drug interactions, and potential uses. Following these medication details, specific information concerning the diagnosis and treatment of several child and adolescent mood and behavior disorders, and in which treatment with mood stabilizers may be helpful, is presented.