Lithium in children of lithium-responding parents

Safety and efficacy of lithium in children and adolescents: A systematic review in bipolar illness

Introduction:

Many clinicians are reluctant to use traditional mood-stabilizing agents, especially lithium, in children and adolescents. This review examined the evidence for lithium’s safety and efficacy in this population.

Methods:

A systematic review was conducted on the use of lithium in children and adolescents with bipolar disorder (BD). Relevant papers published through June 30th 2018 were identified searching the electronic databases MEDLINE, Embase, PsycINFO and the Cochrane Library.

Results:

30 articles met inclusion criteria, including 12 randomized controlled trials (RCTs). Findings from RCTs demonstrate efficacy for acute mania in up to 50% of patients, and evidence of long-term maintenance efficacy. Lithium was generally safe, at least in the short term, with most common side effects being gastrointestinal, polyuria, or headache. Only a minority of patients experienced hypothyroidism. No cases of acute kidney injury or chronic kidney disease were reported.

Conclusions:

Though the available literature is mostly short-term, there is evidence that lithium monotherapy is reasonably safe and effective in children and adolescents, specifically for acute mania and for prevention of mood episodes.

Brain oscillations in bipolar disorder and lithium-induced changes

Electroencephalography (EEG) studies in patients with bipolar disorder have revealed lower amplitudes in brain oscillations. The aim of this review is to describe lithium-induced EEG changes in bipolar disorder and to discuss potential underlying factors. A literature survey about lithium-induced EEG changes in bipolar disorder was performed. Lithium consistently enhances magnitudes of brain oscillations in slow frequencies (delta and theta) in both resting-state EEG studies as well as event-related oscillations studies. Enhancement of magnitudes of beta oscillations is specific to event-related oscillations. Correlation between serum lithium levels and brain oscillations has been reported. Lithium-induced changes in brain oscillations might correspond to lithium-induced alterations in neurotransmitters, signaling cascades, plasticity, brain structure, or biophysical properties of lithium. Therefore, lithium-induced changes in brain oscillations could be promising biomarkers to assess the molecular mechanisms leading to variability in efficacy. Since the variability of lithium response in bipolar disorder is due to the genetic differences in the mechanisms involving lithium, it would be highly promising to assess the lithium-induced EEG changes as biomarkers in genetic studies.

Lithium in the treatment of bipolar disorder: pharmacology and pharmacogenetics

After decades of research, the mechanism of action of lithium in preventing recurrences of bipolar disorder remains only partially understood. Lithium research is complicated by the absence of suitable animal models of bipolar disorder and by having to rely on in vitro studies of peripheral tissues. A number of distinct hypotheses emerged over the years, but none has been conclusively supported or rejected. The common theme emerging from pharmacological and genetic studies is that lithium affects multiple steps in cellular signaling, usually enhancing basal and inhibiting stimulated activities. Some of the key nodes of these regulatory networks include GSK3 (glycogen synthase kinase 3), CREB (cAMP response element-binding protein) and Na(+)-K(+) ATPase. Genetic and pharmacogenetic studies are starting to generate promising findings, but remain limited by small sample sizes. As full responders to lithium seem to represent a unique clinical population, there is inherent value and need for studies of lithium responders. Such studies will be an opportunity to uncover specific effects of lithium in those individuals who clearly benefit from the treatment.

Clinical Usefulness of Loudness Dependence of Auditory Evoked Potentials (LDAEP) in Patients with Bipolar Disorder

While it has been reported previously that the loudness dependence of auditory evoked potentials (LDAEP) is a putative biological marker or a predictor of treatment response, there have been few studies of LDAEP in bipolar disorder. However, a recent study by Park and colleagues raised the possibility that the LDAEP could be useful as a biological marker of bipolar disorder. They found that the LDAEP was significantly higher in normal controls than in patients with either bipolar disorder or schizophrenia. Lee and colleagues also examined the LDAEP in bipolar disorder and normal controls, and found that it differed according to the bipolar phase, being significantly higher in cases of euthymic bipolar disorder, bipolar depression, and bipolar mania. With regard to treatment response, early clinical findings were that a higher LDAEP and a stronger intensity dependence of visual evoked potentials were related to a favorable response to lithium treatment. Juckel and colleagues recently demonstrated that the pretreatment LDAEP could be a predictor of successful prophylactic lithium treatment. The present article reviews the literature in order to determine whether the LDAEP can be used as a biological marker or a predictor of treatment response in patients with bipolar disorder and of manic switch or treatment resistance in patients with major depressive episode(s).

Predictors of lithium response in bipolar disorder

While lithium is generally regarded as the first-line agent for patients with bipolar disorder, it does not work for everyone, which raises the question: can we predict who will be most likely to respond? In this paper, we review the most compelling clinical, biologic, and genetic predictors of lithium response in bipolar disorder. Among clinical factors, the strongest predictors of good response are fewer hospitalizations preceding treatment, an episodic course characterized by an illness pattern of mania followed by depression, and a later age at onset of bipolar disorder. While several biologic predictors have been studied, the results are preliminary and require replication with studies of larger patient samples over longer observation periods. Neuroimaging is a particularly promising method given that it might concurrently illuminate pathophysiologic underpinnings of bipolar disorder, the mechanism of action of lithium, and potential predictors of lithium response. The first genome-wide association study of lithium response was recently completed. No definitive results emerged, perhaps because the study was underpowered. With major new initiatives in progress aiming to identify genes and genetic variations associated with lithium response, there is much reason to be hopeful that clinically useful information might be generated within the next several years. This could ultimately translate into tests that could guide the choice of mood-stabilizing medication for patients. In addition, it might facilitate pharmacologic research aimed at developing newer, more effective medications that might act more quickly and yield fewer side effects.

Evaluation of guideline-concordant care for bipolar disorder among privately insured youth

OBJECTIVE

To describe and quantify the prevalence of treatments and services for youth with bipolar disorder and to assess whether concordance with treatment guidelines is associated with inpatient hospitalization and emergency department visits.

METHOD

Insurance claims of 423 privately insured youth (ages 6-18) having prescription drug coverage and diagnosed with bipolar disorder were examined from the 2000-2001 Thomson Medstat MarketScan database, a national (US) dataset. Treatments and services were examined for the 6 months following the index bipolar disorder diagnosis, defined as the first diagnosis after a diagnosis-free period of 6 months.

RESULTS

The majority of youth did not receive guideline-concordant care. Only 26% (n = 109) received a mood stabilizer or antipsychotic, as recommended, within 1 month of a bipolar diagnosis. Antidepressant monotherapy, which is contraindicated in therapeutic guidelines, was observed for 33% (n = 140) of youth. Less than 40% of youth received adjunctive psychotherapy. Guideline concordance was statistically significantly related to a lower likelihood of an inpatient hospitalization or an emergency department visit.

CONCLUSIONS

Although deviation from guidelines may be warranted in some cases due to individual variation and patient complexity or patient and/or family preferences, these findings suggest that evidence-based guidelines are not followed in clinical practice. Incorporation of guideline-concordant care may increase the likelihood of overall better quality of care and presage better long-term outcomes for youths diagnosed with bipolar disorder.

Treatments in child and adolescent bipolar disorders

The existence of bipolar disorder in adolescents is now clearly established. However, whether bipolarity exists in children is more controversial. We reviewed the literature on acute and prophylactic treatment of bipolar disorder in youths. The guidelines for the treatment of bipolar disorder in children and adolescents are generally similar to those applied in adult practice. But no evidence-based data support the use of mood stabilisers or antipsychotics since we only found two placebo-randomised controlled trials testing the efficacy of lithium in the paediatric literature. Therefore, we support the view that prescriptions should be limited to the most typical cases. In fact, the use of mood stabilisers or antipsychotics in the treatment of bipolar disorder in children and adolescents appears to be of limited use when a comorbid condition, such as attention deficit hyperactivity disorder, occurs unless aggressive behaviour is the target symptom.

Event-related potentials in psychiatry

Electrophysiological assessments of psychiatric disorders have produced a number of promising, highly replicable findings and thus carry the potential of becoming clinically utilizable in the diagnostic or prognostic evaluation of psychopathological conditions. The procedures involved are rather complex technically and the interpretation of the findings require a combined neurophysiological and clinical expertise. On the other hand, electrophysiological techniques are in general non-invasive and relatively inexpensive, and neurophysiology laboratories are widely available in the clinical setting. Among these techniques, event-related potentials (ERPs) are of major interest in psychiatry, particularly since these tools can indicate cortical neuronal dysfunctions, which play a major role in various neuropsychiatric disorders.

Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder

This practice parameter reviews the literature on the assessment and treatment of children and adolescents with bipolar disorder. The parameter focuses primarily on bipolar 1 disorder because that is the type most often studied in juveniles. The presentation of bipolar disorder in youth, especially children, is often considered atypical compared with that of the classic adult disorder, which is characterized by distinct phases of mania and depression. Children who receive a diagnosis of bipolar disorder in community settings typically present with rapid fluctuations in mood and behavior, often associated with comorbid attention-deficit/hyperactivity disorder and disruptive behavior disorders. Thus, at this time it is not clear whether the atypical forms of juvenile mania and the classic adult form of the disorder represent the same illness. The question of diagnostic continuity has important treatment and prognostic implications. Although more controlled trials are needed, mood stabilizers and atypical antipsychotic agents are generally considered the first line of treatment. Although patients may respond to monotherapy, combination pharmacotherapy is necessary for some youth. Behavioral and psychosocial therapies are also generally indicated for juvenile mania to address disruptive behavior problems and the impact of the illness on family and community functioning.

Pharmacological interventions for bipolar youth: Developmental considerations

Despite the high prevalence rate, there have been relatively few controlled studies to systematically examine pharmacological treatments for children and adolescents with bipolar disorder. We review the differences in clinical characteristics between youth and adults with bipolar disorder and the extant literature of pharmacological treatments for children and adolescents with bipolar disorder, as well as discuss the effectiveness of pharmacological interventions for treating children and adolescents who are at familial risk for developing bipolar disorder. Although the number of controlled studies of youth with manic and mixed episodes is rapidly growing, there are few studies examining treatments for depression and the prevention of recurrent affective episodes in this population. Although children and adolescents with bipolar disorder commonly present with co-occurring psychiatric disorders, such as attention-deficit/hyperactivity disorder, there are limited data to guide the treatment of these patients. Recently, studies have begun to characterize prodromal manifestations of bipolar disorder and identify early intervention strategies for treating children and adolescents with an elevated risk for developing bipolar disorder.

A one-year open-label trial of risperidone augmentation in lithium nonresponder youth with preschool-onset bipolar disorder

OBJECTIVE

The aim of this study was to assess the safety and efficacy of risperidone augmentation of lithium in preschool-onset bipolar disorder (BD) among youth who insufficiently respond to lithium monotherapy.

METHOD

Thirty-eight subjects between the ages of 4 and 17 years (mean age = 11.37 +/- 3.8 years) with onset of BD in preschool years (manic or mixed episode) entered this 12-month trial. All subjects received lithium monotherapy. Patients who failed to adequately respond to lithium monotherapy after 8 weeks and those who relapsed after an initial response were given risperidone augmentation for up to 11 months. The Young Mania Rating Scale (YMRS) was the primary outcome measure. Response was defined as a > or =50% decrease from baseline. Additional data were collected on diagnostic comorbidity, family history, number of hospitalizations, perinatal risk factors, history of physical or sexual abuse, Child Depression Rating Scale-Revised (CDRS-R), Clinical Global Impression (CGI) scale for BD (CGI-BP), Children's Global Assessment Scale (C-GAS), and adverse medication effects.

RESULTS

Of the 38 subjects treated with lithium monotherapy, 17 responded, whereas 21 required augmentation with risperidone. Response rate in the youths treated with lithium + risperidone was 85.7% (n = 18/21). Significant predictors of inadequate response to lithium monotherapy requiring augmentation were: (1) attention-deficit/hyperactivity disorder (ADHD), (2) severity at baseline, (3) history of sexual or physical abuse, and (4) preschool age. Combination treatment of lithium and risperidone was found to be safe and well tolerated.

CONCLUSIONS

A substantial proportion of youth with a history of preschool-onset BD treated with lithium were either nonresponders or partial responders. Subsequent augmentation of lithium with risperidone in these cases was well tolerated and efficacious. Potential predictors of lithium nonresponse identified in this study may guide the choice of medications earlier in the treatment process.

Management options for bipolar disorder in children and adolescents

During recent years there has been a dramatic increase in the use of psychotropic medication for the treatment of bipolar disorder (BPD) in children. There is an emerging set of data to support this use.Mood stabilizers, including lithium and valproic acid (valproate sodium), have generally formed the mainstay of treatment in children and adolescents with BPD. However, the atypical antipsychotics, such as risperidone, aripiprazole, and quetiapine may be more effective as first-line treatment options and in some ways easier to use than the traditional mood stabilizers. As in adults, mood stabilization is often difficult to achieve in pediatric patients with BPD, and combined treatment with mood stabilizers and atypical antipscyhotics is commonly used. Data from controlled trials of psychotropic medications in children and adolescents with BPD are very limited, and hence, in the majority of cases physicians base their treatment decisions on data from case reports, case series, or open trials. More controlled studies of both monotherapy and polypharmacotherapy for BPD in children and adolescents are needed.

Prepubertal bipolar disorder: proper diagnosis should lead to better treatment response

Treatment research in prepubertal bipolar disorder remains in a rudimentary stage. Phenomenological evidence suggests it is a heterogeneous disorder with varying degrees of rapid cycling, aggression, and psychosis often accompanied by comorbid diagnoses of attention deficit hyperactivity disorder, conduct disorder, oppositional defiant disorder, and anxiety disorders including obsessive compulsive disorder. Longitudinal and family history studies suggest prepubertal bipolar disorder may be more treatment-resistant than later-onset bipolar disorder. Neurobiological studies to guide treatment, though promising, remain in their infancy. Clinical trials to date (mostly open studies) often have lumped together subjects with manic, hypomanic, and mixed presentations with different and/or undiagnosed comorbidities, making meaningful comparisons of treatment response difficult. Randomized, double-blind, placebo-controlled trials are needed to clarify best treatment options for bipolar subtypes with and without comorbid disorders. More homogeneous diagnostic groupings based on episode and duration criteria and a more patient-centered, symptom-based approach should be considered in treatment designs.

Treatment of mania in children and adolescents

Bipolar disorder (BPD) is a severe and complex illness that seriously disrupts the lives of those afflicted. Increased rates of suicide attempts and completions, poorer academic performances, disturbed interpersonal relationships, increased rates of substance abuse, legal difficulties, and multiple hospitalizations all have been associated with BPD. At least 1% of children and adolescents have this disorder. This commentary is designed to review and summarize the recent literature on the treatment of manic and/or hypomanic phases of BPD in children and adolescents.

Treatment guidelines for children and adolescents with bipolar disorder

Clinicians who treat children and adolescents with bipolar disorder desperately need current treatment guidelines. These guidelines were developed by expert consensus and a review of the extant literature about the diagnosis and treatment of pediatric bipolar disorders. The four sections of these guidelines include diagnosis, comorbidity, acute treatment, and maintenance treatment. These guidelines are not intended to serve as an absolute standard of medical or psychological care but rather to serve as clinically useful guidelines for evaluation and treatment that can be used in the care of children and adolescents with bipolar disorder. These guidelines are subject to change as our evidence base increases and practice patterns evolve.

Somatic treatment of bipolar disorder in children and adolescents

The currently available data from randomized, controlled trials and a considerable amount of open clinical data suggest that adolescent-onset bipolar disorder probably responds to the same agents as adult-onset bipolar disorder. Research examining psychopharmacologic treatment approaches in the early-onset bipolar disorder is limited, however. Methodologic problems include small sample sizes, lack of comparison groups, retrospective designs,and lack of standardized measures. In addition, sometimes no clear differentiation is made between mania and bipolar disorder, the latter term being used broadly in the literature. Often the studies show that symptoms improve because of treatment, but the functioning of the patients does not improve significantly. More research is clearly needed in all aspects of this disorder but especially in examining the efficacy of various types of treatment, its longitudinal course, and diagnostic issues. The indications for, and the overall duration of, long-term maintenance therapy need further study.Many adolescents and children with bipolar disorder do not respond to any of the first-line pharmacologic treatments; therefore, studies with novel agents should be extended to patients in this age range. Furthermore, physicians will probably continue to use combination therapies when confronted by either lack of efficacy or delayed onset of efficacy with a single agent. Thus, such resultant drug-drug interactions also should also be systematically studied [97].

Recognition of childhood depression: personal reminiscences

Prior to 1970, childhood depression was not considered a valid clinical entity by American psychiatrists. One of the early clues was provided in the 1950s by the author's observation of depressive symptoms in children and young adolescents with undescended testicles. This finding was extended to children with several chronic diseases, many of whom exhibited depressive symptoms as well. Eventually, depressive symptomatology was found in children without any physical disorders. This was followed by the introduction of a diagnostic instrument, called the Children's Affective Rating Scale (CARS), later converted into a more formal system called the Child Assessment Schedule (CAS). A provisional classification of childhood depression was published in 1972. Our examination of children with depressive disorders has revealed several modes of family interaction, of which the most important were: separation from important love objects; depreciation and rejection; and affective disorders in parents. Several children with bipolar disorder stimulated our interest in this disorder and led to a pilot study of children of bipolar, lithium-responding parents. Some of these children with bipolar illness had a clear-cut response to lithium and were strong augmenters of the average evoked potentials (EPs). Next, our group investigated the urinary excretion of norepinephrine and its metabolites in chronically depressed children who differed from a normal control group. The foregoing studies, along with major contributions by other child psychiatrists, eventually led to the acceptance of childhood depression as a clinical entity in US psychiatry. The acceptance of juvenile bipolar disorder had to await further research by a new generation of child and adult psychiatrists.

Predicting response to lithium in mood disorders: role of genetic polymorphisms

Lithium is considered to be the first choice mood stabilizer in recurrent mood disorders. Its widespread and large-scale use is the result of its proven efficacy. In spite of this fact, patients have been observed to show a variable response to lithium treatment: in some cases it is completely effective in preventing manic or depressive relapses, while in other cases it appears to show no influence on the disease course. The possible definition of a genetic liability profile for adverse effects and efficacy will be of great help, as lithium therapy needs at least 6 months to be effective in stabilizing mood disorders. During the last few years, a number of groups have reported possible liability genes. Lithium long-term prophylactic efficacy has been associated with serotonin transporter protein, tryptophan hydroxylase and inositol polyphosphate 1-phosphatase variants. A number of other candidate genes and anonymous markers did not yield positive associations. Therefore, even if some positive results have been reported, no unequivocal susceptibility gene for lithium efficacy has been identified. Although the available data may not currently allow a meaningful prediction of lithium response, future research is aimed at the development of individualized treament of mood disorders, including the possibility of 'pharmacological genetic counseling'.

Biological predictors of lithium response in bipolar disorder

In order to prescribe lithium appropriately to patients with bipolar disorder, predictors of lithium response are helpful. The present paper reviews the biological predictors of lithium response. As a positive predictor of lithium response, the following have been reported: strong loudness dependence of the auditory-evoked N1/P2-response; higher brain lithium concentration; lower inositol monophosphatase (IMPase) mRNA expression; higher serotonin-induced calcium mobilization; increased N-acetyl-aspartate peak and decreased myo-inositol peak; white matter hyperintensity; decreased intracellular pH; higher frequency of phospholipase C gamma-1 (PLCG1)-5 repeat and PLCG1-8 repeat; and C973A polymorphism in the inositol polyphosphate 1-phosphatase gene. In contrast the following have been reported as a predictor of negative lithium response: epileptiform abnormality of electroencephalography; human leukocyte antigen type A3; decreased phosphocreatine peak area after photic stimulation; and homozygotes for the short variant of the serotonin transporter gene. Most of the possible biological predictors of better lithium response, such as lower IMPase mRNA levels, white matter hyperintensity, lower brain intracellular pH, enhanced calcium response, and PLCG1-5 repeat had been detected as risk factors for bipolar disorder, suggesting that bipolar disorder responding well to maintenance lithium treatment is a distinct category having a certain neurobiological basis, although these findings need further replication. The search for biological predictors of lithium response is still in its infancy. Most of the laboratory or neuroimaging techniques used in these studies are not easily performed in clinical settings, so the development of an easy and useful laboratory test is needed.

The use of mood stabilizers and atypical antipsychotics in children and adolescents with bipolar disorders

The clinical use of mood stabilizers and antipsychotics in children and adolescents with bipolar disorders has increased significantly over the past few years. These agents have multiple effects and interactions. This articles reviews the studies that support the use of mood stabilizers and atypical antipsychotics in children and adolescents with bipolar disorders and presents information on these agent's pharmacokinetics, dosing, and drug interactions.

Annotation: The use of psychotropic medications in children: an American view

BACKGROUND

Psychotropic medications have become an integral component in the treatment of children with mental illnesses.

METHODS

Selective reviews of the empirical evidence for the efficacy of psychotropic medications and studies of their use patterns were reviewed.

RESULTS

Very strong efficacy for at least the short-term benefits and safety of stimulant medications was found and some good efficacy and safety evidence for the treatment of anxiety and depressive disorders with seratonin reuptake inhibitors (SSRI) was also found. Efficacy for tricyclic antidepressants to treat attention deficit hyperactivity disorder was found but the presence of significant side effects makes them less the drugs of choice. Other medications are presented but with less rigorous evidence. Studies of use found that stimulant medications are extensively prescribed in the US by both psychiatrists and primary care physicians. SSRI are also prescribed extensively but not to the extent of stimulants and are more frequently prescribed by psychiatrists.

CONCLUSIONS

There is now good evidence for the efficacy of some psychotropic agents and their use is an integral component in the management of childhood mental illnesses.

Pharmacogenetics of bipolar disorder

To review the pharmacogenetics of bipolar disorders, the authors searched databases for genetic association and linkage studies involving response to long-term prophylactic lithium treatment, as well as treatment with antidepressants or clozapine. Significant ethnic variations in the metabolism and efficacy of antidepressants, as well as clozapine, have been reported by several groups. Systematic studies suggest that that genetic factors affect the response to prophylactic lithium treatment. Numerous associations between the three traits of interest and candidate gene polymorphisms have been proposed. Among these, an association between the serotonin transporter gene and response to serotonin reuptake inhibitors appears robust. Considerable interest has also focused on serotonergic gene polymorphisms and response to clozapine. Response to pharmacotherapy in bipolar disorders may be mediated by genetic factors, but the role played by heritability is unknown.

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.

Lithium long-term treatment in mood disorders: clinical and genetic predictors

Lithium is the most widely used long-term treatment for recurrent mood disorders. Despite its proven efficacy, patients show a variable response, ranging from complete efficacy to no influence at all. This paper reviews possible predictors of response focusing on molecular genetic studies. The functional polymorphism in the upstream regulatory region of the serotonin transporter gene (5-HTTLPR) has been associated with lithium long-term efficacy in two independent studies, marginal associations have been reported for tryptophan hydroxylase and inositol polyphosphate 1-phosphatase (INPP1). A number of other candidate genes and anonymous markers did not yield positive associations. Therefore, even though some positive results have been reported, no unequivocal susceptibility gene for lithium efficacy has been identified.

Genetic factors and treatment of mood disorders

OBJECTIVES

This paper reviews the pharmacogenetics of mood disorders.

METHODS

We have searched the literature for published studies and abstracts relevant for genetic effects in acute antidepressant treatment and in long-term prophylactic treatment.

RESULTS

The most promising findings to date show an association of the serotonin transporter (5-HTT) gene and the response to serotonin reuptake inhibitors. Genetic factors also appear to play a significant role in the outcome of long-term lithium treatment. The phenotype of lithium-responsive bipolar disorder is associated with stronger genetic effects as well as with an increased phenotypic homogeneity.

CONCLUSIONS

Genetic factors likely influence treatment response in mood disorders. Clarifying their precise role will have implications for treatment as well as for understanding the pathophysiological mechanisms of these disorders.

Mood disorders in children and adolescents: psychopharmacological treatment

Mood disorders are the leading causes of morbidity and mortality in children and adolescence. As a result, many adolescents are treated with psychopharmacologic agents such as antidepressants and mood stabilizers. To date, research into the safety and efficacy of these medications has lagged behind clinical practice. Several controlled trials of antidepressants in this population have recently been completed or are ongoing, yet few controlled trials of mood stabilizers have been conducted. Although acute efficacy of antidepressants is being addressed, many questions remain about pharmacological treatment of early-onset mood disorders. This article will focus on unmet research needs for the psychopharmacologic treatment of child and adolescent mood disorders.

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.

Event-related potentials. Do they reflect central serotonergic neurotransmission and do they predict clinical response to serotonin agonists?

The increasing knowledge concerning anatomical structures and cellular processes underlying event-related potentials (ERP) as well as methodological advances in ERP data analysis (e.g. dipole source analysis) begin to bridge the gap between ERP and neurochemical aspects. Reliable indicators of the serotonin system are urgently needed because of its role in pathophysiology and as target of pharmacotherapeutic interventions in psychiatric disorders. Converging arguments from preclinical and clinical studies support the hypothesis that the loudness dependence of the auditory evoked N1/P2-response (LDAEP) is regulated by the level of central serotonergic neurotransmission. Dipole source analysis represents an important methodological advance in this context, because the two N1/P2-subcomponents, generated by the primary and secondary auditory cortex known to be differentially innervated by serotonergic fibers, can be separated. A pronounced LDAEP of primary auditory cortices is supposed to reflect low central serotonergic neurotransmission, and vice versa. LDAEP is a parameter with potential clinical value since subgroups of patients with a serotonergic dysfunction can be identified and can be treated more specifically. In depressed patients, a significant relationship between strong LDAEP, indicating low serotonergic function, and a favorable response to SSRI has been found. Additionally, there is evidence from several studies with patients with affective disorders implicating a strong LDAEP as a predictor of favorable response to a preventive lithium treatment.

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.

Identifying psychiatric patients with serotonergic dysfunctions by event-related potentials

The increasing knowledge concerning anatomical structures and cellular processes underlying event-related potentials (ERP) as well as methodological advances in ERP data analysis (e.g. dipole source analysis) is beginning to bridge the gap between ERP and neurochemical aspects. Reliable indicators of the serotonin system are urgently needed because of its role in pathophysiology and as target of pharmacotherapeutic interventions in psychiatric disorders. Converging arguments from preclinical and clinical studies support the hypothesis that the loudness dependence of the auditory evoked N1/P2-response (LDAEP) is regulated by the level of central serotonergic neurotransmission. Dipole source analysis represents an important methodological advance in this context, because the two N1/P2-subcomponents, generated by the primary and secondary auditory cortex known to be differentially innervated by serotonergic fibres, can be separated. A pronounced LDAEP of primary auditory cortices is supposed to reflect low central serotonergic neurotransmission, and vice versa. LDAEP is a parameter with potential clinical value since subgroups of patients with a serotonergic dysfunction can be identified and can be treated more specifically. In depressed patients, a significant relationship between strong LDAEP, indicating low serotonergic function, and a favourable response to SSRI has been found. Additionally, there is evidence from several studies with patients with affective disorders that a strong LDAEP predicts favourable response to a preventive lithium treatment.

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.

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.

Juvenile mood disorders and office psychopharmacology

Mood disorders afflict pediatric patients, cause significant impairment, and interfere with normal development. Increasingly, pediatricians are called on to assess and collaborate with mental health practitioners in medicating children and adolescents with mood disorders. Approaching the juvenile with a primary emphasis on clarifying the diagnoses, determining environmental antecedents and sequelae, and investigating suicide risk enables the pediatrician to institute appropriate treatment. Despite limited data from controlled studies, psychotherapy often is used for mild to moderate depression. Pharmacotherapy is indicated in cases unresponsive to psychotherapy and in severe or suicidal cases. First-line pharmacotherapy for depressed adolescents is usually an SRI followed by the atypical or TCA antidepressants. Bipolar disorder typically requires an aggressive medication regimen, including anticonvulsants, lithium, or a combination, as well as environmental modifications. With severe, difficult, or refractory cases, mental health consultation is recommended to clarify diagnoses and to provide psychotherapy and medication input.

Practice parameters for the assessment and treatment of children and adolescents with bipolar disorder. American Academy of Child and Adolescent Psychiatry

These practice parameters describe the assessment and treatment of early-onset bipolar disorder based on scientific evidence regarding diagnosis and effective treatment and on the current state of clinical practice. Given the paucity of research on bipolar disorder in children and adolescents, many of the treatment recommendations are drawn from the adult literature. Although the same diagnostic criteria are used as for adults, youth may differ with regard to the developmental presentation of symptoms and comorbid psychiatric disorders. Treatment involves the combination of pharmacotherapy and adjunctive psychosocial interventions. Antimanic agents (primarily lithium or valproic acid) are the mainstays of pharmacotherapy. The treatment focuses on (1) amelioration of acute symptoms; (2) the prevention of relapse; (3) the reduction of long-term morbidity; and (4) the promotion of long-term growth and development. These parameters were approved by Council of the American Academy of Child and Adolescent Psychiatry on June 5, 1996, and were previously published in J. Am. Acad. Chil Adolesc. Psychiatry, 1997, 36:138-157.

Bipolar disorder in children and adolescents: current challenges

OBJECTIVE

To demonstrate the diagnostic and treatment challenges in juvenile-onset bipolar disorder.

METHOD

Three case vignettes are outlined to demonstrate different bipolar presentations in children and adolescents.

RESULTS

These case examples illustrate important issues in the diagnosis and management of juvenile-onset bipolar disorder. These issues include diagnostic confusion with atypical initial presentation and the effect of developmental factors on symptom expression. The relationship among genetic risk, early affective instability, and the stress generated by affectively ill family members is complex and circular. Comorbidity with disruptive behaviour disorders, as well as anxiety disorders, is demonstrated by the cases discussed. Comorbid disorders may affect outcome and require separate treatment intervention. There is evidence for the prophylactic antimanic effect of lithium carbonate in children and adolescents, but its specificity as an antimanic agent is still uncertain. There is less evidence, at present, for effectiveness of other mood stabilizers in this age group, although sodium valproate may prove more effective in mixed mania and rapid cycling, which are so often seen with early-onset bipolar disorder.

CONCLUSIONS

While the existence of juvenile-onset bipolar disorder is no longer in dispute, several outstanding issues related to diagnosis and long-term management remain. Careful prospective research will be necessary to sort out these issues definitively.

AACAP official action. Practice parameters for the assessment and treatment of children and adolescents with bipolar disorder

These practice parameters describe the assessment and treatment of early-onset bipolar disorder based on scientific evidence regarding diagnosis and effective treatment and on the current state of clinical practice. Given the paucity of research on bipolar disorder in children and adolescents, many of the treatment recommendations are drawn from the adult literature. Although the same diagnostic criteria are used as for adults, youth may differ with regard to the developmental presentation of symptoms and comorbid psychiatric disorders. Treatment involves the combination of pharmacotherapy and adjunctive psychosocial interventions. Antimanic agents (primarily lithium or valproic acid) are the mainstays of pharmacotherapy. The treatment focuses on (1) amelioration of acute symptoms; (2) the prevention of relapse; (3) the reduction of long-term morbidity; and (4) the promotion of long-term growth and development. These parameters were approved by Council of the American Academy of Child and Adolescent Psychiatry on June 5, 1996.

Developmental pathways to bipolarity: are juvenile-onset depressions pre-bipolar?

This article approaches the question of bipolarity in childhood and adolescence from an "adult" perspective. It argues that clinically ascertained juvenile depressions--with onsets typically in late childhood or early adolescence--have affinity to bipolar spectrum disorders based on (1) early age at onset; (2) even gender ratio; (3) prominence of irritability, labile moods, and explosive anger indicative of mixed episodes; (4) high rates of "comorbid" substance abuse; (5) questionable response to antidepressants and/or brief hypomanic switches; (6) high rates of recurrence; (7) familial affective loading; and (8) frequent superposition on affective temperamental dysregulation. Building on the last point, the author submits that dysthymic, cyclothymic, and hyperthymic temperaments represent putative developmental pathways to bipolarity (as contrasted to "inhibited" anxious-phobic types, which appear related to nonbipolar outcomes.

Treatment of bipolar disorder in children and adolescents

OBJECTIVE

To evaluate the current status of research in the treatment of bipolar disorder in children and adolescents.

METHOD

A Medline search was conducted for articles on pharmacological or psychosocial treatment of bipolar disorder in children and adolescents.

RESULTS

There are no controlled studies with adequate sample size of the efficacy of lithium (or any other treatments) in bipolar children and adolescents. Two large open studies suggest that, overall, lithium is beneficial, but there also are reports of lithium resistance in bipolar children and adolescents. Small open studies suggest that mood-congruent delusions and hallucinations may be treated successfully with lithium alone. Data on adjuncts or alternatives to lithium in bipolar children and adolescents are sparse. Several controlled studies have been published on psychosocial treatment of child and adolescent depression, but none on mania.

CONCLUSIONS

Pharmacological and psychosocial treatments of bipolar disorder in children and adolescents are understudied. There is a need for well-designed, controlled studies of lithium and alternative medications as well as adjunctive psychosocial treatments.

Preliminary study of magnetic resonance imaging characteristics in 8- to 16-year-olds with mania

OBJECTIVE

To examine magnetic resonance imaging (MRI) characteristics in children and adolescents with mania according to DSM-III-R criteria.

METHOD

A convenience sample of consecutively referred 8- to 16-year-old manic (n = 10) and normal (n = 5) subjects were assessed using the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present Episode Version, the Children's Global Assessment Scale, and the Family History-Research Diagnostic Criteria. MRI scans were obtained from unsedated subjects using a 1.5 T MR scanner to acquire T1-weighted coronal and sagittal images and T2-weighted axial images. Images were assessed by blind clinical interpretation, ratings of T2-weighted deep white matter hyperintensities and petalia, and computer-assisted volumetric analysis of ventricular and cerebral volumes.

RESULTS

Eight of 10 manic subjects and all 5 controls completed the scans. Scans of 4 manic subjects and 1 control subject showed ventricular or white matter abnormalities by clinical interpretation. Significant findings were positive correlations between increasing age and both right and left ventricular volumes. Two of the 8 manic subjects and no controls had confluent subcortical hyperintensities.

CONCLUSIONS

MRI brain scanning was feasible in 8- to 16-year-olds. Preliminary findings from clinical interpretations and structured ratings suggest structural differences between young manic and normal subjects. Investigations of larger samples are needed to better characterize the differences.

Update on lithium carbonate therapy in children and adolescents

The use of lithium to treat child and adolescent psychiatric disorders is becoming more common. Since the publication of the report of The Committee on Biological Aspects of Child Psychiatry of the American Academy of Child Psychiatry in 1978, a considerable body of literature has accumulated on the efficacy of lithium in treating adolescent bipolar disorders, childhood aggression, and behavioral disorders associated with mental retardation and developmental disorders. Efforts to understand lithium's mechanism(s) and refinements in psychiatric diagnosis have contributed to its growing use.

Early findings from a pharmacokinetically designed double-blind and placebo-controlled study of lithium for adolescents comorbid with bipolar and substance dependency disorders

1. This manuscript reports the early findings from a National Institute on Drug Abuse funded study of lithium for adolescents dually diagnosed with bipolar and substance dependency disorders. The authors elected to publish early findings in the hope that it would accomplish a twofold mission. 2. The first part would be to encourage other investigators to participate in research in this area and the second would be to heighten the awareness of clinicians that adolescents presenting with either one of these disorders might also have the other. 3. The early findings demonstrated the feasibility of recruiting, retaining and monitoring this complex population on an outpatient basis. 4. Steady-state serum lithium levels were pharmacokinetically placed in the study range, 0.9-1.3 mEq/L. Preliminary results are encouraging in finding lithium more effective than placebo for alleviating both the substance dependency and the mood disordered symptomatology. 5. The characteristics of the study population to date have been chronicity of both disorders, impairment in the severe range in multiple areas of functioning, and strong family histories for both affective and substance use disorders. The substance dependency was to both alcohol and marijuana; but all subjects also had marked polydrug abuse. 6. In order to best monitor lithium compliance and drug/alcohol use during protocol, randomly timed weekly serum and urine assays were obtained. 7. The implications of these early findings for the outcome of this acute phase study and for the development of longitudinal treatment strategies are discussed.

Lithium in hospitalized children at 4 and 8 weeks: mood, behavior and cognitive effects

Eleven psychiatrically hospitalized children were treated with lithium carbonate for a minimum of 8 weeks. Based on literature review, their psychopathology, diagnoses and family history suggested they would be positive lithium responders. Weekly ratings in behavioral domains showed children's improvement in areas of self control, aggression and irritability, more obvious at 8 than 4 weeks. However, of seven children studied with double blind crossover, improvement behaviorally and cognitively was maintained on placebo. Only three of 11 children improved enough to be discharged on lithium. Implications of lithium's anti-aggressive and anti-manic effects in children are discussed.

Pharmacological treatment of adolescent psychiatric disorders

Psychopharmacological treatments of major psychiatric disorders during adolescence, including depression, anxiety disorders, schizophrenia, and attention-deficit disorder, are reviewed. Pharmacokinetic and psychological aspects specific to adolescence, which if ignored may impair or abolish drug efficacy, are examined. Recommendations are given for safe use of tricyclic antidepressants, monoamine oxidase inhibitors, and neuroleptics in this age group. Areas where future research is needed to make rational pharmacological choices are noted.