Mood stabilizers in children and adolescents

Effect size of lithium, carbamazepine, and sodium valproate in child and adolescent bipolar 1 disorder during manic phase: A prospective open-label study

AIM

The aim was to evaluate the "effect size (ES)," tolerability, and acceptability of lithium, carbamazepine, and sodium valproate in the acute phase treatment of pediatric Bipolar 1 disorder patients during manic phase.

MATERIALS AND METHODS

This hospital-based, prospective, open-label study included 67 patients in manic phase of bipolar I disorder, aged 6-17 years, after informed consent by the caregivers. The patients were randomly assigned to the lithium group (n = 30), carbamazepine group (n = 20), and sodium valproate group (n = 17). They were assessed with the Schedule for Affective Disorders for School Age Children's-Present and Life time version administered to the parent and child separately, Conner's Abbreviated Rating Scale, and Cassidy Scale for Manic States (CSMS). Lithium was started in the dose of 30 mg per kg of body weight, carbamazepine in the dose of 10-20 mg/kg/day, and sodium valproate in the dose of 10-20 mg/kg body weight. Antipsychotic (chlorpromazine [CPZ] 100-500 mg per day or haloperidol up to 750 mg of CPZ equivalent) was allowed in the study. Injection haloperidol 10 mg and injection promethazine 50 mg intramuscular were allowed for initial 3-5 days to combat acute agitation. Rescue medication such as injection lorazepam 2-4 mg intramuscular was allowed throughout the study duration. The patients were rated weekly on CSMS, Bipolar Clinical Global Impression, Udvalg for kliniske Undersogelser Side Effect Rating Scale, and side effect checklist for lithium, sodium valproate, and carbamazepine, respectively. The serum level of concerned drug was obtained at weekly intervals and dose hiked, if needed to get target serum level.

RESULTS

The response rate was 90% in lithium group, 70% in carbamazepine group, and 88% in sodium valproate group on the basis of ≥33% reduction from baseline CSMS. The effects of change of CSMS over the 6 weeks across the three treatment group were found to be highly statistically significant.

CONCLUSIONS

In the acute phase treatment of pediatric bipolar 1 disorder patients during manic phase, the ES for lithium was 0.85, for carbamazepine 0.71, and for sodium valproate 0.84. These agents are well tolerated in treating bipolar disorder in children.

Proposed treatment for adolescent psychosis. 2: Bipolar illness

Bipolar illnesses are typically considered as disorders primarily occurring in adult life, but a substantial number have their onset during the teenage years. Any acute illness in the teenage years affects social, emotional and educational development disproportionately, as it may prevent the normal transitions and learning experiences inherent in adolescence. Additionally, there is some evidence for a lack of early recognition or for misdiagnosis in early-onset cases of psychiatric disorders in general and the psychotic disorders in particular, with consequent increased suffering and impairment of functioning. Finally, bipolar affective disorders rarely present with one single episode followed by full and permanent recovery, but are usually illnesses characterised by a relapsing and remitting course through adult life. Prompt and effective recognition and treatment may therefore not merely reduce immediate impact but may also set up patterns of understanding and treatment compliance with longer-term implications. In this paper, I consider the particular features of bipolar affective disorder in adolescence and to describe a practical framework for its management. In view of the relative lack of age-specific research findings, particularly in respect of treatment effectiveness, I draw heavily upon clinical practice and extrapolation from studies carried out among adult sufferers.

Lithium treatment alleviates impaired cognition in a mouse model of fragile X syndrome

Fragile X syndrome (FXS) is caused by suppressed expression of fragile X mental retardation protein (FMRP), which results in intellectual disability accompanied by many variably manifested characteristics, such as hyperactivity, seizures and autistic-like behaviors. Treatment of mice that lack FMRP, Fmr1 knockout (KO) mice, with lithium has been reported to ameliorate locomotor hyperactivity, prevent hypersensitivity to audiogenic seizures, improve passive avoidance behavior and attenuate sociability deficits. To focus on the defining characteristic of FXS, which is cognitive impairment, we tested if lithium treatment ameliorated impairments in four cognitive tasks in Fmr1 KO mice, tested if the response to lithium differed in adolescent and adult mice and tested if therapeutic effects persisted after discontinuation of lithium administration. Fmr1 KO mice displayed impaired cognition in the novel object detection task, temporal ordering for objects task and coordinate and categorical spatial processing tasks. Chronic lithium treatment of adolescent (from 4 to 8 weeks of age) and adult (from 8 to 12 weeks of age) mice abolished cognitive impairments in all four cognitive tasks. Cognitive deficits returned after lithium treatment was discontinued for 4 weeks. These results show that Fmr1 KO mice exhibit severe impairments in these cognitive tasks, that lithium is equally effective in normalizing cognition in these tasks whether it is administered to young or adult mice and that lithium administration must be continued for the cognitive improvements to be sustained. These findings provide further evidence that lithium administration may be beneficial for individuals with FXS.

Initiation and change of psychotropic medication regimens among adolescents in inpatient care

OBJECTIVE

The purpose of this study was to compare clinical and service utilization profiles of adolescents admitted to inpatient treatment with and without a psychotropic medication regimen, and estimate correlates of medication use separately for the two groups.

METHOD

Comprehensive data on clinical characteristics and service utilization of 517 adolescents enrolled in Medicaid who were admitted to three inpatient hospitals (one for-profit and two nonprofit) in a mid-Atlantic state were used. Medication correlates were examined with bivariate statistics (chi-square and t-test) and multivariate logistic regressions.

RESULTS

Psychotropic medication was prescribed for the majority (90.5%) of adolescents at discharge. During their inpatient stay, 76.3% of the youths who were not on medication at admission (n = 190) initiated medication use, and 45% admitted with prior medication (n = 327) had a medication change. Adolescents admitted with and without medication differed on all sociodemographic and clinical characteristics except age, suicidality, and hospital. Controlling on demographic, clinical, and service history characteristics, hospital setting was the only correlate significantly associated with both initiation and change.

CONCLUSIONS

Institutional factors may be more important than clinical factors in appraising medication patterns in inpatient settings. Interventions to ensure the development and implementation of medication management guidelines may need to be tailored to the climate and culture of the provider organization as well as directly to individual practitioners, parents or adolescents themselves.

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.

Do male and female adolescents differ in the effect of individual and family characteristics on their use of psychotropic drugs?

This study assesses the effects of individual and family characteristics on psychotropic drug use among male and female adolescents. The sample included 2,396 subjects attending two middle schools and two high schools. Respondents completed self-administered questionnaires covering gender, age, body mass index, smoking, alcohol use, illicit drug use, tiredness during the daytime, self-reported personality traits, family conditions, and psychotropic drug use. The data were analyzed using logistic models. The prevalence of frequent psychotropic drug use (for headache, tiredness, nervousness, anxiety, insomnia) was 43.0% overall; twice as high among girls than boys. Among the girls, frequent psychotropic drug use was associated with frequent tiredness during the daytime (adjusted odds ratio OR 2.03, 95% CI 1.61-2.57), smoking (2.02, 1.50-2.71), alcohol use (1.34, 1.04-1.74), higher body mass index (>18 kg/m(2), 1.54, 1.16-2.04), poor family atmosphere (1.33, 1.03-1.72), and being worried (1.93, 1.53-2.43) or easily becoming irritable (1.28, 1.01-1.62). In boys the factors with significant ORs were frequent tiredness during the daytime (2.21, 1.67-2.93), alcohol use (1.52, 1.15-2.01), and being worried (1.70, 1.28-2.26) or easily becoming irritable (1.42, 1.06-1.89); univariate analysis revealed a significant relationship with smoking and family atmosphere. An association was also observed for illicit drugs in both sexes and for age > or = 17 years in girls. Individual and family characteristics have marked influence on psychotropic drug use among both male and female adolescents. Preventive measures should be taken to make adolescents and their parents more aware of the risks and to improve their living conditions.

[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.

Lithium: clinical considerations in internal medicine

Bipolar Disorders affect up to 5% of the population. While the pharmacological options for the treatment of bipolar disorder have expanded over the past several years, lithium remains an inexpensive and efficacious treatment for bipolar disorder. Lithium has been demonstrated to be an effective treatment for acute mania, bipolar depression, the prophylactic treatment of bipolar disorder, and as an augmentation agent in the treatment of unipolar major depression. Lithium also is the only mood stabilizer that has been demonstrated to lower the suicide rate in patients with bipolar disorder. Use in special populations, side effects and toxicity, and drug interactions are discussed. Important laboratory monitoring guidelines are included in this review. Lithium remains an important intervention for the treatment of mood disorders.

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.

Clinical experience with Topiramate to counteract neuroleptic induced weight gain in 10 individuals with autistic spectrum disorders

Children and adolescents with autistic spectrum disorders are treated with neuroleptics to limit behavioral disturbances such as aggression, hyperactivity and self-injury. They may experience substantial weight gain when undergoing treatment with atypical antipsychotics actually employed. Topiramate (TPM) is an antiepileptic medication that is being progressively demonstrating a wider spectrum of action, mainly as an agent for weight control and as a mood stabilizer. It was administered to a group of children and adolescents with autistic spectrum disorders with the aim of reversing weight gain. This is an open study over an observation period of 18 months of 10 children and adolescents, eight males and two females, mean age 13 years, SD+/-3.6, range 8-19 years with a diagnosis of autistic disorder or pervasive developmental disorder not otherwise specified according to DSM-IV. Starting dosage of TPM was 0.5 mg/kg followed by titration of 0.5 mg/kg on a weekly basis, up to 1-3 mg/kg/day as the maintenance dosage. Eight subjects were undergoing long-term treatment with risperidone, one with pimozide and one was temporarily not on antipsychotics. Six patients took TPM on a regular basis and four dropped out. Variable degrees of weight reduction were observed in four patients, two subjects showed weight increase. Behavioral adverse effects were observed in three patients causing rapid withdrawal of the medication. TPM should be used with caution in autistic spectrum disorders because this population has a high risk of behavioral disruption.

Concomitant pharmacotherapy among youths treated in routine psychiatric practice

OBJECTIVES

The aim of this study was to assess rates and correlates of concomitant pharmacotherapy in children and adolescents treated by psychiatrists in a broad range of clinical settings.

METHODS

Cross-sectional data on 392 child and adolescent patients aged 2-17 years from the 1997 and 1999 American Psychiatric Practice Research Network Study of Psychiatric Patients and Treatments were used, and weighted estimates are provided.

RESULTS

Findings indicate that 84% of child and adolescent patients received one or more psychopharmacologic medications; 52% of patients treated with medications received concomitant pharmacotherapy (i.e., two or more medications). Patients who were treated with psychopharmacologic treatments received a median of 2 medications (range, 1-6). Highest rates of concomitant pharmacotherapy were among patients with bipolar disorder (87%). Correlates of concomitant pharmacotherapy included: (1) having a diagnosis of bipolar disorder, (2) having co-occurring Axis I or II disorders or general medical conditions, and (3) currently receiving treatment in an inpatient setting.

CONCLUSIONS

Over 40% of child and adolescent patients of psychiatrists were prescribed two or more psychopharmacologic medications. Patients with chronic and clinically complex conditions were more likely to receive concomitant pharmacotherapy. Most often, efficacy of U.S. Food and Drug Administration (FDA)-approved medications has been examined as monotherapy, and cautions on drug interactions and off-label use derived from multiple sources accompany each product. With high rates of concomitant pharmacotherapy among children and adolescents in psychiatric care, additional research on efficacy and safety of this treatment strategy is necessary.

A review of the growing evidence base for pediatric psychopharmacology

This article provides an update of pediatric psychopharmacologic treatment evidence and focuses on six classes of medications in pediatric populations: psychostimulants, mood stabilizers, SSRIs, tricyclic antidepressants, antipsychotic agents, and other agents. The evidence is organized by disorder so that it is most useful to practicing clinicians. We begin each section with a brief introduction and summary of the findings published before January 1998. Priority is given to clinical trials that use random assignment and use of a comparison group (ie, placebo-control, head-to-head comparison, or cross-over design). Serious concerns remain about the efficacy and safety of many of these agents for use in children and adolescents. While a great progress is being made, there is clearly much work left to be done.

Pharmacologic management of behavioral instability in medically ill pediatric patients

PURPOSE OF REVIEW

Behavioral instability in children and adolescents is a vexing problem faced by many clinicians. This dilemma is magnified when it presents in a child with an acute medical condition. Effective treatment in these cases with medications may help to reduce morbidity and facilitate appropriate medical care for the underlying condition.

RECENT FINDINGS

There are many reviews, but few studies examine the treatment of behavioral instability in the pediatric population. There are even fewer that address behavioral instability in the presence of a comorbid medical condition. Many effective agents may worsen a given condition or interfere with the treatment of that condition. There are no prospective studies addressing this issue.

SUMMARY

Many psychotropic medications must be considered when treating behavioral instability in medically ill children. Antihistamines, benzodiazepines, and antipsychotics may be of particular benefit. Definitive research is lacking and necessary to develop appropriate clinical guidelines. This article considers the most current literature and provides an overall summary of the topic.

Trends in psychotropic drug use in a child psychiatric hospital from 1991-1998

OBJECTIVE

This study was undertaken to analyze inpatient prescribing patterns of psychotropic drugs in a child psychiatric hospital from 1991-1998.

METHODS

Hospital pharmacy dispensing data were reviewed. Total admissions, first admissions, and readmissions were identified, and medication status of all patients at admission and at discharge was ascertained. Patterns of total psychotropic drug use and proportionate use of each drug class (antidepressants, mood stabilizers, antipsychotics stimulants, and alpha-2 antagonists) were evaluated.

RESULTS

Controlling for the 2.3-fold rise in hospital admissions, there was a 73.0% increase in the use of psychotropic drugs from 1991-1998. The greatest relative increase was in the use of alpha-2 antagonists (from 3.3% to 23.6%). Significant increases were also observed for antidepressants (from 35.6% to 77.3%), mood stabilizers (from 14.9% to 32.6%), and stimulants (from 10.5% to 20.6%). Antipsychotic use showed no net change, although use of atypical agents largely supplanted that of conventional drugs.

CONCLUSIONS

These findings document a marked and continuing increase in psychotropic drug use in child psychiatric inpatients during the 1990s. This trend occurred against a background of increased hospital admissions and shorter lengths of stay. Most of the increased use is accounted for by newer agents, even though data supporting their efficacy and safety in this population are limited.

Recognizing and treating uncommon behavioral and emotional disorders in children and adolescents who have been severely maltreated: bipolar disorders

Although it was assumed for many years that children do not experience bipolar disorder, it has been recently recognized that some children do. Those who have been severely maltreated may be at an increased risk for developing a bipolar disorder. This article explores the symptoms of the bipolar disorder as well as strategies for distinguishing these symptoms from those of children experiencing more common disorders. Treatment strategies, including the use of medication, for children experiencing bipolar disorder and their families are examined.

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].

The Subjective Experience of Youth Psychotropic Treatment

The psychotropic treatment of youth is increasing dramatically. This article examines child and adolescent psychopharmacological research and argues that social work practice and research must examine the complex relationships, social and psychological, in youth pharmacologic treatment. Regarding identity formation, this article explores the developmental consequences when youth adopt an illness narrative to make sense of everyday medication treatment. A conceptual framework for mapping the socio-cultural context of youth medication management is outlined. In the conclusion, youth psychotropic treatment is connected to a perplexing 'interpretive gap,' which highlights the subjective quality of medication treatment.

Disordered gambling in adolescents : epidemiology, diagnosis, and treatment

Rapid expansion of legalized gambling has been associated with increased rates of gambling disorders among adults and adolescents worldwide. Epidemiologic studies suggest that, in North America, up to 6% of adults and 20% of adolescents have a gambling problem. Despite increasing prevalence rates of gambling disorders, little research is available on how to treat such disorders in adolescents. Much of what is known about how to treat adolescent problem and pathological gambling comes from research on psychosocial and psychopharmacologic treatments for adult pathological gambling. Risk factors for adolescent gambling disorders include male gender, alcohol and drug use, deviant peers, family history of gambling, and impulsive behavior. While several risk factors characterize disordered gambling among adolescents, the extent to which these characteristics are related remains to be determined. In terms of screening for adolescent problem and pathological gambling, several instruments designed to reflect the Diagnostic and Statistical Manual of Mental Disorders diagnostic criteria for pathological gambling are available. Psychosocial approaches used to treat adult pathological gambling include Gamblers Anonymous, cognitive-behavioral therapy (CBT), and motivational enhancement therapy (MET). Among adolescents, CBT as well as an eclectic therapy have been helpful in reducing problematic gambling behavior. In terms of pharmacotherapy, three classes of psychotropic drugs have been used to treat adult pathological gambling - serotonin reuptake inhibitors, opioid antagonists, and mood stabilizers. While some of these pharmacotherapies have been efficacious in treating adult pathological gambling, additional double-blind, placebo-controlled studies are needed to determine the long-term effectiveness of these treatments. No known study has evaluated the use of psychopharmacologic agents in treating adolescent pathological gambling. Possible reasons for the lack of research on treatment for adolescent gambling disorders include lack of motivation to pursue treatment, feelings of self-control, and negative perception of therapy. Referrals from parents, teachers, and peers of adolescents, as well as community outreach programs, may be useful in successfully deriving a treatment population. Clinicians are advised to be sensitive to behavioral risk factors and to screen for disordered gambling in high risk adolescents. A combination of CBT and MET, as well as medication for any comorbid psychiatric condition, is recommended.

Depression and bipolar support alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in children and adolescents

OBJECTIVE

To focus attention on the critical unmet needs of children and adolescents with mood disorders and to make recommendations for future research and allocation of healthcare resources.

METHOD

The 36-member Consensus Development Panel consisted of experts in child/adolescent or adult psychiatry and psychology, pediatrics, and mental health advocacy. Reviews of the literature concerning youth mood disorders were performed on the subjects of risk factors, prevention, diagnosis, treatment, and services delivery, and opinions and experiences of mental health advocates were obtained.

RESULTS

The Consensus Development Panel listened to presentations and participated in discussions. Independent workgroups of clinicians, scientists, and mental health advocates considered the evidence and prepared preliminary statements. Workgroup leaders presented drafts for discussion by the Consensus Development Panel. The final document was reviewed by the entire group and edited to incorporate input from all participants.

CONCLUSIONS

Evidence suggests high rates of unmet needs for children and adolescents with depression or bipolar disorder. Training is largely limited to child mental health specialists; general psychiatrists, pediatricians, and other primary care physicians receive little or no training. As a result, treatment patterns may reflect adult treatment plans that are not validated for youths. Effective treatments have been identified and some preliminary prevention models have been developed, but they are not yet widely applied. Patients experience limited exposure to clinicians adequately trained to address their problems and little information to guide care decisions, particularly concerning bipolar disorder. National efforts are required to restructure healthcare delivery and provider training and to immediately develop more advanced research on pathophysiology, prevention, and services delivery effectiveness.

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.

Treatment recommendations for the use of antipsychotics for aggressive youth (TRAAY). Part II

OBJECTIVE

To develop treatment recommendations for the use of antipsychotic medications for children and adolescents with serious psychiatric disorders and externalizing behavior problems.

METHOD

Using a combination of evidence- and consensus-based methodologies, recommendations were developed in six phases as informed by three primary sources of information: (1) current scientific evidence (published and unpublished), (2) the expressed needs for treatment-relevant information and guidance specified by clinicians in a series of focus groups, and (3) consensus of clinical and research experts derived from a formal survey and a consensus workshop.

RESULTS

Fourteen treatment recommendations on the use of atypical antipsychotics for aggression in youth with comorbid psychiatric conditions were developed. Each recommendation corresponds to one of the phases of care (evaluation, treatment, stabilization, and maintenance) and includes a brief clinical rationale that draws upon the available scientific evidence and consensus expert opinion derived from survey data and a consensus workshop.

CONCLUSION

Until additional research from controlled trials becomes available, these evidence- and consensus-based treatment recommendations may be a useful approach to guide the use of antipsychotics in youth with aggression.

A 5-year-old boy with recurrent mania successfully treated with carbamazepine

In the present paper the clinical symptomatology and treatment of childhood mania that was first seen in a child at 5 years of age and which re-emerged at age 7, is reported. The patient presented at the child and adolescent psychiatric outpatient clinic of Istanbul Medical University with the typical symptoms of mania such of hyperactivity, euphoria, irritability, dangerous and risky behavior, decreased sleep, and age-inappropriate sexual behavior. He was treated with carbamazepine safely and effectively without any major side-effects. Clinical phenomenology and treatment of the condition are discussed with relevant literature.

Valproate in very young children: an open case series with a brief follow-up

We report nine cases of juvenile mania, of which six began in the preschool years. We provide validation by clinical description, family history of bipolar disorder, worsening on stimulants, and considerable mood stabilization with divalproex. This is a relatively new area of clinical observation, and systematic studies are needed to firmly establish this diagnostic category in very young children. Our case series enriches the existing scant literature and provide the rationale for the use of mood stabilizers rather than stimulants in this juvenile population. However, no controlled studies exist on the efficacy and safety of valproate in this age group; lithium that has received greater clinical attention, has not been subjected to controlled studies either. Our clinical observations with divalproex are preliminary but encouraging.

The pharmacologic treatment of the early phase of first-episode psychosis in youths

OBJECTIVES

To summarize available knowledge about pharmacologic treatments that are used for first-onset (or early) psychosis in youths, with particular consideration of the prodromal stage and the effectiveness and safety of novel antipsychotic drugs and mood stabilizers.

METHOD

A computerized search of medical databases (for example, Medline and Embase), a manual searching of articles and textbooks, and the use of vignettes to highlight treatment issues.

RESULTS

There are limited data about the effectiveness and safety of psychotropic agents for youths with psychosis and scarce information about the drug treatment of the prodromal stage of early psychosis in all age groups. The available data are encouraging, although the newer agents are not without safety concerns.

CONCLUSIONS

Despite the paucity of studies, there is a range of psychotropics that may be used in the early stages of psychotic illness in youths. Drug choice is influenced by several factors, including the clinical picture, side effect profile, and patient preference. In certain situations, the decision may be not to use medication.

Psychoactive medication prescribing practices for U.S. children: gaps between research and clinical practice

OBJECTIVE

To determine national pediatric prescribing practices for psychotropic agents and to examine these practices in view of the available evidence concerning their safety and efficacy in this age group.

METHOD

Prescribing data from 2 national databases based on surveys of office-based medical practices were determined and reviewed vis-à-vis available safety and efficacy evidence.

RESULTS

Data indicate that levels of psychotropic prescribing in children and adolescents are greatest for stimulants, resulting in nearly 2 million office visits and 6 million drug "mentions" in 1995. Selective serotonin reuptake inhibitors were the second most prescribed psychotropic agents, while anticonvulsant mood stabilizers (prescribed for a psychiatric reason), tricyclic antidepressants, central adrenergic agonists, antipsychotics, benzodiazepines, and lithium were also prescribed for a substantial number of office visits. Comparison of prescribing frequencies with available safety and efficacy data indicates significant gaps in knowledge for commonly used agents.

CONCLUSIONS

Most psychotropic agents require further sustained study to ensure appropriate health care expenditures and vouchsafe children's safety. Recommendations for researchers, parents, federal agencies, and industry are offered as a means to accelerate the pace of research progress.