Mood stabilizers in hospitalized children with bipolar disorder: a retrospective review

Divalproex sodium in the treatment of pediatric psychiatric disorders

Divalproex sodium is an anticonvulsant that is used extensively in adults with indications for epilepsy, acute mania and migraine prophylaxis. It has been used in children and adolescents as a first-line agent for mania in bipolar disorder. Its efficacy as a mood stabilizer has been established, and there have been studies outlining its efficacy as an agent effective in the treatment of conduct disorder, disruptive behavior disorders, aggression and explosive disorder. Longer-acting formulations are now available that cause less gastrointestinal side effects and can also be taken once a day, thus potentially increasing adherence, an important factor in this patient population. Future directions would include developing a more potent valproic acid formulation with fewer side effects, completing randomized controlled trials to establish the efficacy of divalproex sodium in various other pediatric psychiatric disorders, establishing the relative efficacy of the compound in head-to-head comparisons with other mood stabilizers, examining systematically the value of the compound in multimodal pediatric psychiatric treatment packages, and complete effectiveness trials that demonstrate the short- and long-term effectiveness of the compound in the real world of clinicians. In this drug profile, divalproex sodium and its uses in the pediatric population for psychiatric conditions are reviewed.

Pharmacologic treatment of bipolar disorder in children and adolescents

This review focuses mainly on published articles regarding the treatment of school-aged children and adolescents with pediatric bipolar disorder. In light of systematic reviews, large randomized controlled trial data are emphasized wherever possible. This review addresses the treatment of acute manic/mixed episodes, including combination treatment, the preliminary literature regarding bipolar depression among youth, treatment in the face of comorbid conditions, and maintenance treatment. Suggestions regarding future directions are offered. A clinical vignette describing a teen with bipolar disorder is presented and bipolar medications, dosing, efficacy, side effects, contraindications, and succinct comments on each medication are summarized.

The Use of Antiepileptic Drugs (AEDs) for the Treatment of Pediatric Aggression and Mood Disorders

Aggressive symptomatology presents across multiple psychiatric, developmental, neurological and behavioral disorders, complicating the diagnosis and treatment of the underlying pathology. Anti-Epileptic Drugs (AEDs) have become an appealing alternative in the treatment of aggression, mood lability and impulsivity in adult and pediatric populations, although few controlled trials have explored their efficacy in treating pediatric populations. This review of the literature synthesizes the available data on ten AEDs - valproate, carbamazepine, oxcarbazepine, phenytoin, lamotrigine, topiramate, levetiracetam, zonisamide, gabapentin and tiagabine - in an attempt to assess evidence for the efficacy of AEDs in the treatment of aggression in pediatric populations. Our review revealed modest evidence that some of the AEDs produced improvement in pediatric aggression, but controlled trials in pediatric bipolar disorder have not been promising. Valproate is the best supported AED for aggression and should be considered as a first line of treatment. When monotherapy is insufficient, combining an AED with either lithium or an atypical anti-psychotic can result in better efficacy. Additionally, our review indicates that medications with predominately GABA-ergic mechanisms of action are not effective in treating aggression, and medications which decrease glutaminergic transmission tended to have more cognitive adverse effects. Agents with multiple mechanisms of action may be more effective.

A prospective open-label trial of extended-release carbamazepine monotherapy in children with bipolar disorder

OBJECTIVE

The aim of this study was to evaluate the safety and efficacy of extended release carbamazepine (CBZ-ER) monotherapy in the treatment of pediatric bipolar disorder (BD).

METHOD

This was an 8-week, open-label, prospective trial of CBZ-ER monotherapy (788 +/- 252 mg/day) to assess the effectiveness and tolerability of this compound in treating pediatric bipolar spectrum disorders. Assessments included the Young Mania Rating Scale (YMRS), Clinical Global Impressions-Improvement scale, Children's Depression Rating Scale, and Brief Psychiatric Rating Scale. Adverse events were assessed through spontaneous self-reports, vital signs weight monitoring, and laboratory analysis.

RESULTS

Of the 27 participating children with BD, 16 (59.%) completed the study. CBZ-ER treatment was associated with statistically significant, but modest, levels of improvement in mean YMRS scores (-10.1 +/- 10.2, p < 0.001) with end-point mean YMRS score (21.8 +/- 12.2) suggesting a lack of complete resolution of mania. CBZ-ER treatment also resulted in significant improvement in the severity of depressive, attention-deficit/hyperactivity disorder, and psychotic symptoms. With the exception of 2 participants who discontinued due to skin rash, CBZ-ER was well tolerated with marginal increase in body weight (0.8 +/- 2.5 kg, p = 0.04) and was not associated with any abnormal changes in laboratory parameters.

CONCLUSIONS

Open-label CBZ-ER treatment was beneficial for the treatment of BD in children. Future controlled trials are warranted.

Pharmacologic treatment of pediatric bipolar disorder

Bipolar disorder (BPD) is being diagnosed with increasing frequency in the pediatric population as the phenomenology of this disorder is becoming more clearly delineated. Early diagnosis and treatment of pediatric BPD is important to minimize psychosocial disability and improve prognosis. Traditional mood stabilizers and atypical antipsychotic agents are frequently used to treat BPD in youth, and there are emerging data to support their use in this population. This article provides a review of the literature on appropriate pharmacologic treatment strategies for BPD in children and adolescents. The complex treatment issues of comorbid BPD and attention deficit/hyperactivity disorder also are addressed.

[Pharmacotherapy in bipolar disorders during childhood and adolescence]

OBJECTIVE

Bipolar disorders during childhood and adolescence are rare, but serious and highly recurrent disorders, often associated with negative outcome. Pharmacotherapy, including Lithium, other mood stabilizers and typical antipsychotic agents, is the first-line treatment in bipolar disorders and often necessary for many months or years.

METHOD

A computerized medline-search (Pubmed) was made for prospective studies and reviews of bipolar disorder in this age-group published during the last 10 years, which were then reviewed for their relevance.

RESULTS

Despite the widespread use of substances whose efficacy for adults is well-established, there is a substantial lack of empirical data regarding the efficacy and safety in the treatment of bipolar disorder in children and adolescents. Placebo-controlled studies are very rare, and the interpretation of the existing data is complicated by the diagnostic controversy about bipolar disorder in children. Side-effects are more common in children and adolescents than in adults.

CONCLUSIONS

Combination therapy may be favoured in cases of severe and psychotic bipolar disorder. Needed are more placebo-controlled studies and long-term studies on the efficacy and safety of mood stabilizers and atypical antipsychotic agents in the treatment of children and adolescents 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.

Psychopharmacology of pediatric bipolar disorder: a review

RATIONALE

Pediatric bipolar disorder (PBD) is a chronic and debilitating psychiatric illness. It is associated with many short-term and long-term complications including poor academic and social performance, legal problems and increased risk of suicide. Moreover, it is often complicated by other serious psychiatric disorders including attention deficit hyperactivity disorder, oppositional defiant disorder, conduct disorder and substance use disorders. For these reasons, there is a need for effective treatment for PBD.

OBJECTIVES

To review available data from published reports of the treatment of PBD, highlighting those treatment practices for which there is scientific evidence. To suggest directions for future research.

MATERIALS AND METHODS

A comprehensive Medline search was performed to identify published reports from 1995 to 2006. Reports with the greatest methodological stringency received greater focus.

RESULTS

There is limited evidence from double-blind, placebo-controlled trials regarding the treatment of PBD. Available data suggests that lithium, some anticonvulsants and second-generation antipsychotics may be equally beneficial in the acute monotherapy for youth with mixed or manic states. However, because of limited response to acute monotherapy, there is increased justification for combination therapy. There is very limited data on the treatment of the depressed phase of bipolar illness in the youth. Also, very few studies have addressed the treatment of comorbidities and maintenance/relapse prevention in PBD.

CONCLUSION

Although significant progress was made in the treatment of youth with bipolar disorder, there is a need for more methodologically stringent research to more precisely define evidence-based treatment strategies for PBD.

Pediatric Bipolar Disorder: Evidence-Based Psychopharmacological Treatments

TOPIC

Pediatric bipolar disorder can cause severe disturbances in global functioning. Diagnosing pediatric bipolar disorder is challenging due to the range of symptom expression, developmental differences as compared to adults, presence of comorbid disorders, and developing diagnostic criteria. Treating this disorder can be equally challenging due to frequent symptom relapse and the dearth of research until recently on effective psychopharmacological interventions that guide clinical prescribing practices.

PURPOSE

This paper will help child psychiatric nurses have a better understanding of the unique presentation of pediatric bipolar disorder to facilitate selection of appropriate medication treatment options, taking into account symptom presentation, presence of comorbid diagnosis, drug efficacy, adverse effects, and drug-drug interactions based on research findings.

SOURCES

Literature specific to assessment and psychopharmacological treatment of pediatric bipolar disorder was reviewed.

CONCLUSIONS

Screening of youth with mood spectrum problems for bipolar disorder should occur in every diagnostic assessment and should be ongoing due to range of mood symptoms and the cyclical and episodic nature of this disorder. Youth with bipolar disorder may manifest symptoms and course that differ from adults. Additionally, co-occuring disorders are common in this population, which can complicate medication selection. Psychopharmacological treatment with the use of specific mood stabilizers and/or atypical antipsychotic medications is warranted depending on symptom presentation; however, monotherapy with mood stabilizers has not demonstrated effectiveness in long-term remission of pediatric bipolar symptoms. Recent research indicates that a combined treatment with two mood stabilizers or a mood stabilizer and an antipsychotic holds promising results for pediatric bipolar I, for youth with acute manic symptoms plus psychosis, and for long-term remission of symptoms.

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.

[Therapy with lithium salts in child and adolescent psychiatry--clinical efficacy and practical recommendations]

Lithium salts are pharmacologically classified as mood stabilizers and are medications of first choice for the treatment of manic episodes and the prevention of relapse in bipolar disorders in children and adolescents. Moreover, these drugs can be used to treat episodic impulsive aggressiveness. With regard to their use in the treatment of children and adolescents, however, there are limitations to several preparations on the market in Germany. The evidence level for the treatment of acute mania in adolescents is II, while it is only III-IV for treatment of the same disorder in children. There is only anecdotal evidence of relapse prevention in bipolar disorder in childhood (level of evidence: V), whereas the level of evidence for adolescence is higher (IV). With respect to episodic impulsive aggressiveness, there is a good evidence base (II) for treatment of the disorder in both children and adolescents. An evidence level of II indicates that at least one well designed, randomized, controlled study has been carried out; an evidence level of III is based upon non-randomized studies, an evidence level of IV upon non-experimental studies, and an evidence level of V indicates that evidence is limited to reports or opinions stated by expert circles and consensus conferences, and to clinical experience. Due to the narrow therapeutic window, the dosage should be based on serum concentrations of lithium between 0.6 and 1.2 mmol/l and should be adapted according to the clinical picture. Usually, lithium preparations are administered twice a day: in the morning and in the evening. Side effects have to be monitored very carefully. Serum concentrations higher than 1.5 mmol/l are dangerous. All potential side effects, with the exception of very infrequently occurring renal damage, are reversible by means of dose reduction or, if necessary, by discontinuation of medication with lithium.

Nonepileptic uses of antiepileptic drugs in children and adolescents

Antiepileptic drugs are often prescribed for nonepileptic neurologic and psychiatric conditions. The United States Food and Drug Administration has approved several antiepileptic drugs for the treatment of neuropathic pain, migraine, and mania in adults. For pediatric patients, use of antiepileptic drugs for non-seizure-related purposes is supported mainly by adult studies, open-label trials, and case reports. Summarized here is the published literature for or against the use of antiepileptic drugs for neuropathic pain, migraine, movement disorders, bipolar disorder, aggressive behavior, and pervasive developmental disorders in children and adolescents. Using the American Academy of Neurology's four-tiered classification scheme for a therapeutic article and translation to a recommendation rating, there are no nonepileptic disorders for which antiepileptic drugs have been established as effective for pediatric patients. Valproate and carbamazepine are "possibly effective" in the treatment of Sydenham chorea, and valproate is "probably effective" in decreasing aggressive behavior. Carbamazepine is "probably ineffective" in the treatment of aggression, and lamotrigine is "possibly ineffective" in improving the core symptom of pervasive developmental disorders. Despite the frequent use of antiepileptic drugs in the treatment of juvenile bipolar disorder, migraine, and neuropathic pain, the data are insufficient to make recommendations regarding the efficacy of antiepileptics in these conditions in children and adolescents.

Oxcarbazepine in the treatment of child psychiatric disorders: a retrospective chart review

Though not considered a first-line treatment, oxcarbazepine has become an option in the expanding effort to ameliorate severely dysregulated mood and behavioral symptoms in youth. Like most pharmaceuticals in child and adolescent psychiatry, oxcarbazepine is not U.S. Food and Drug Administration (FDA)-approved for the treatment of psychiatric disorders. A search of the world literature found a single case report pertaining to this topic. This paper is a chart review of 14 children and adolescents treated with oxcarbazepine who presented with moderate to severe problems with anger and irritability associated with a range of Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) diagnoses. A majority (70%) of patients was treatment-resistant to prior psychopharmacologic efforts, and 70% were receiving combined treatment with other agents in addition to oxcarbazepine. Moderate clinical global improvement was reported in 50% of patients receiving oxcarbazepine; tolerability was good in 86%.

Prepubertal bipolar disorder: available pharmacological treatment options

Awareness of bipolar spectrum disorders in children is rapidly increasing, with a more precise definition of their clinical subtypes and early signs. Paediatric bipolar disorder can lead to an important impairment in scholastic, familial and social functioning, and to a higher risk for substance abuse and suicide. In the context of a multimodal approach, the core treatment of early-onset bipolar disorder is pharmacological. This review focuses on the empirical evidence for pharmacotherapy in paediatric bipolar disorder. Mood stabilizers, including lithium, and older and newer anticonvulsivants will be considered, in mono- or polypharmacy. Atypical antipsychotics will be considered in more severe and/or treatment-resistant manic or mixed episodes. Finally, the prophylaxis of intercritical phases and the management of specific challenging conditions, such as bipolar depression and attention deficit hyperactivity disorder, with bipolar comorbidity, will be reviewed.