Pediatric Bipolar Disorder: Evidence-Based Psychopharmacological Treatments

Second-Generation Antipsychotics in Management of Acute Pediatric Bipolar Depression: A Systematic Review and Meta-analysis

Objectives: To evaluate the efficacy in reduction of depressive symptoms, and safety and tolerability of second-generation antipsychotics (SGAs) to manage pediatric bipolar depression (PBD). Methods: We conducted a systematic review for randomized clinical trials (RCTs) for PBD in MEDLINE, Scopus, and EMBASE. Four (quetiapine: 2, lurasidone: 1, olanzapine-fluoxetine combination [OFC]: 1) out of 569 studies met the criteria for inclusion in meta-analysis. RevMan was used for statistical analysis, and the mean difference (MD) between mean children's depression rating scale-revised (CDRS-R) score was used to measure treatment difference between SGA and placebo. Results: Lurasidone displayed a significant reduction in depressive symptoms (MD -5.70, 95% confidence interval [CI] -8.67 to -2.73) in PBD, followed by OFC (MD -5.00, 95% CI -8.64 to -1.36) and quetiapine (MD -2.30, 95% CI -6.80 to 2.20; MD 1.00, 95% CI -9.88 to 11.88). The response was significantly higher for lurasidone (59.5% vs. 36.5%; p < 0.001) and OFC (78.2% vs. 59.2%, p = 0.003) compared with placebo. There was no statistically significant MD in treatment and response rates between quetiapine and placebo in all RCTs. The weighted mean CDRS-R total score difference was -4.58 (95% CI -6.59 to -2.56) and overall effect was significant (p < 0.00001). Importantly, the p value for heterogeneity was 0.46, which indicated that there was no heterogeneity between outcomes of the studies. The number needed to treat (NNT) for lurasidone was 4.3, followed by OFC (NNT = 5.3) and quetiapine (NNT = 12.5; NNT = 25). Conclusion: Our findings showed lurasidone and OFC were more efficacious than placebo for acute depressive episodes in PBD. RCTs of treatments for PBD remain scarce pressing the need for more research.

American Psychological Association practice guidelines for psychopharmacology: Ethical practice considerations for psychologists involving psychotropic use with children and adolescents

OBJECTIVES

This study discusses the implications of the American Psychological Association's 2011 Practice Guidelines for Pharmacology as they apply to psychologists working with juvenile clients. Special considerations apply due to concerns about the developmental side effects that occur when psychotropic medications are prescribed to children and adolescents.

METHODS OR DESIGN

This study provides recommendations for implementing each of the Practice Guidelines. Constructive criticism of the Practice Guidelines is also discussed with the aim of improving service delivery.

RESULTS

This study provides specific recommendations for psychologists regarding obtaining adequate knowledge about psychopharmacology to inform clients or consult with physicians. Suggestions are made for continuing education requirements for psychologists who work with juveniles.

CONCLUSIONS

Recommendations are made for psychologists working with juveniles to increase their knowledge of psychotropic medications for a more ethical and informed voice regarding the prescribing of such medications.

Nursing children and adolescents with bipolar disorder: assessment, diagnosis, treatment, and management

TOPIC

The role of the mental health nurse in the assessment, diagnosis, treatment, and management of children and adolescents with bipolar disorder in community and hospital settings.

PURPOSE

In many areas of clinical practice, mental health nurses have more contact with service users than any other professional group. They are therefore well placed to support children and adolescents with bipolar disorder during first contact with primary care services, through engagement with specialist mental health services, and in accessing early intervention and crisis services. This paper summarizes the contribution that child and adolescent mental health nurses make to the care of children and adolescents with bipolar disorder.

SOURCES

This paper is based on evidence from systematic reviews; meta-analyses and best practice evidence from CINAHL; EMBASE; MEDLINE, PsychINFO; Cochrane Collaboration; National Institute for Health and Clinical Excellence; National Collaborating Centre for Mental Health; NHS Centre for Reviews and Dissemination; Oxford Centre for Evidence Based Medicine; United States Agency for Healthcare Research and Quality.

CONCLUSIONS

Child and adolescent mental health nurses work with children and adolescents who have bipolar disorder in a range of settings. These include community mental health services, hospitals, and schools. Due to the multidisciplinary nature of the treatment and management of bipolar disorder during childhood and adolescence, nurses have a major role to play in providing frontline assessment services, monitoring treatment, and delivering psychosocial interventions.

Ethical issues in psychopharmacology of children and adolescents

PURPOSE OF REVIEW

This summary of the literature published over recent years focuses on the ethical aspects of interventions with psychotropic medication in child and adolescent psychiatry. Ethical issues of pharmacotherapy concern aspects of research, safety, indicated use, enhancement, information and evidence-based practice.

RECENT FINDINGS

The literature on pharmacological interventions suggests changes in prescribing patterns for some substance classes owing to regulatory authorities' warnings. For most of the commonly used medications in children and adolescents no sound database about efficacy and safety is available and knowledge about adverse events and long-term safety remains poor. This is due to a general lack of clinical trials in this population. Legislative efforts have tried to improve safety and labelling of medicines for children. Ethical issues of enhancement in minors have been increasingly discussed over recent years.

SUMMARY

The ethical aspects of psychopharmacotherapy in minors are still rarely discussed in the literature. Practical questions of research and treatment ethics such as a need for information for children and parents are pointed out; conflicts of evocation and access to care for special populations in need are identified in a field lacking adequate ethical and clinical research.

Pediatric bipolar disorder: recognition in primary care

PURPOSE OF REVIEW

Bipolar disorder (BPD) is increasingly diagnosed in youth in both outpatient and inpatient settings. Research on BPD in youth has also increased dramatically; this paper summarizes issues of clinical relevance in primary care, advancements in the last year, and areas in which more research is needed.

RECENT FINDINGS

Key issues and new developments are summarized in the following areas such as epidemiology and relevance, assessment and differential diagnosis, patient and family decision support, shared decision making and triage, treatment, and monitoring and collaboration with mental health professionals. Recent practice guidelines have important implications for diagnosis and treatment.

SUMMARY

Early-onset BPD appears to have a more severe course and more comorbidity than later life onset, as well as longer delays in treatment seeking. Affected children show differences in cognitive functioning and neuroanatomy compared with the general population. Assessment of BPD in children needs to be comprehensive and longitudinal, as diagnosis remains a debated topic. Medications are a primary part of treatment, but more double-blind, placebo-controlled trials are needed. Psychosocial adjunctive treatment is important. Children with a family history of BPD are at risk for impaired functioning and psychopathology; high-risk studies will increase our understanding of the onset and course of BPD.