Bipolar Medications for Children

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Bipolar Medications for Children

Bipolar medications for children are a subject of controversy due to the unknown long term side effects , the lack of knowledge about pediatric bipolar disorder in general, and the paucity of good research on the effectiveness of the medications themselves. The Journal of the American Academy of Child and Adolescent Psychiatry published guidelines in March of 2005 on treatment of bipolar disorder in pediatric patients. A flow chart on bipolar medications was included in that paper.

The guidelines were arrived at by analyzing the research available and ranking that research in the order of its quality. This is the best information on what bipolar medications should be chosen when treating this disorder in children . I am not a doctor, and this is merely an attempt to explain a protocol already outlined by doctors who are experts in pediatric bipolar disorder.

This web page and its linking pages are meant to serve as a more simplified and accessible summary for parents or professionals who are attempting to understand or ask questions about the choices in bipolar medications. Children who have early onset bipolar have been harmed by antidepressants and stimulants. Therefore it is important for us to be more educated about the bipolar medications used to treat children.

Don’t Depend on the Doctors to Give you the Necessary Information

Parents and professionals may fail to ask important questions about bipolar medications because they are intimidated by psychiatrists. Unfortunately some psychiatrists can be cold and dismissive; they may fail to tell you about side effects or other important information you need to know about the medications your child are on. You can’t depend on them to monitor your child’s medications, or to make choices without input from you.

Play an Active Role in Assessing your Child’s Response to Medication

When it comes to your child you cannot be too cautious or too informed. Sometimes the only way to help your child, is to take the lead in forging a relationship with your doctor. Ask questions, stay educated, and be a good observer and reporter. Hopefully this information will give you some confidence to discuss questions or concerns you may about bipolar medications.

The guidelines are divided into two sections with six progressive stages in each section. If one stage does not work, the doctor can move to the next stage.

Key Points About Guidelines

The guidelines are not applicable for Bipolar II , only for Bipolar I, manic or mixed, with or without psychosis.

I asked experts in the field why this is the case and was told, that basically due to lack of research and lack of funding this is the only information that is available. Information about Bipolar I, depressed is included but less conclusive.

This will be change as more studies are done on early onset bipolar. In fact, since the guidelines were published in 2005, both Risperidone (Risperdol) and Aripiprazole (Abilfy) were approved by the FDA to treat Pediatric Bipolar Disorder.

Even though guidelines for treating Bipolar II are less conclusive, recent research suggests many of the children presenting with Bipolar NOS will convert to Bipolar I, and even some of those with BPII will convert to BP I. (Birmaher, 2006).

Before reading the guidelines it is important to understand the two groups of bipolar medications used to treat early onset: mood stabilizers and atypical antipsychotics.

Below is a summary of the research supporting the effectiveness of the drugs commonly prescribed for early onset bipolar. Keep in mind unless specified otherwise, the effectiveness refers to Bipolar I, manic or mixed in adults and children.

Mood Stabilizers

Lithium Carbonate or Lithium

The best research evidence for child bipolar- including some suggestion that it helps with child depressive episodes and evidence that it does help with adult depressive episodes.

Click here for more extensive information on lithium.

Divalproex or Depakote

The second best research evidence for child bipolar including some suggestion that it helps with child depressive episodes.

Carbamazapine or Tegretol

Pretty good evidence that it helps with adults.

Oxcarbazepine or Trileptal

Some case reports or suggestion that it is helpful for children. No evidence that it is helpful for adults, no hard evidence that it is helpful for children.

Topiramate or Topamax

Some evidence it’s helpful for kids.

Gabapentin (Neurontin)

No evidence that its helpful.

Atypical Antipsychotics

Respiridone or Risperdol

Good evidence for adults, some evidence for children.

Olanzapine or Zyprexa

Good evidence for adults some evidence for children. Also evidence for adults with both manic/ mixed and depressive episode of BP.

Quetiapine or Seroquel

Good evidence for adults some evidence for children. Also evidence for adults with depressed episode of BP. Click here for more information about seroquel, specifically it's relationship to anger.

Click here for more extensive information on seroquel

Aripiprazole or Abilfy

Good evidence for adults some evidence for children.

Ziprasidone or Geodon

Good evidence for adults some evidence for children.

Clozaril or Clozapine

Some evidence for children.


Summary of the Guidelines

Child Bipolar medication is summarized in the Treatment Guidelines for Children and Adolescents with Bipolar disorder: Child Psychiatric Workgroup on Bipolar Disorder

The first part of these guidelines are written to address Bipolar I Disorder, manic or mixed without psychosis. The second part guidelines addresses Bipolar I Disorder, manic or mixed with psychosis.

BIPOLAR I DISORDER, MANIC OR MIXED WITHOUT PSYCHOSIS

Bipolar I Disorder, Manic or Mixed without Psychosis.

Definitions

Monotherapy is the use of one drug.

Augmentation is the addition of another drug.

Partial response means that you see improvement, but not enough.

Mood stabilizers

Lithium

Depakote( Valproate)

Tegratol ( Carbamazepine)

Antipsychotics

Zyprexa (Olanzapine)

Seroquel (quetiapine)

Risperdol( Risperidone)

Abilify (Aripiprazole)

Stage 1 Monotherapy One Drug

The first choice if your child has this diagnosis is either a mood stabilizer or an antipsychotic from the list above. The choice of which will depend on the Doctor’s assessment of the symptoms. The Child Bipolar Medications listed here are the ones recommended by the panel, based on their experience and the evidence.

Stage 1A Augmentation

If your child has a partial response then the medication guidelines suggest adding another one of the agents above. This is called augmentation.

For example:

Lithium plus Depakote

Lithium plus Zyprexa

Lithium + Seroquel

Lithium plus Risperdol

Depakote + Zyprexa

Depakote + Seroquel

Depakote + Risperdol

Tegratol+Zyprexa

Tegratol + Seroquel

Tegratol+ Risperdal

Stage 2 Switch the Monotherapy Agent

If your child has no response to the augmenting agent then the medication guidelines suggest switching the primary monotherapy agent.

Example: Your child was on lithium, had a partial response, was tired with lithium and Depakote, with no improvement, then the monotherapy agent would be switched to Tegratol.

If your child has no response in Stage 1 then the Child Bipolar medication guidelines suggest switching to another monotherapy agent.

Example your child tried Lithium and it didn’t work then Depakote might be tried

If your child has a partial response to Stage 2 then the Child Bipolar medication guidelines suggest going back to Stage 1a. Augmenting the agent that is having a partial response.

Example your child tried lithium and it didn’t work, they tried Depakote and it worked partially. The Dr may try your child on Depakote and Seroquel.

Stage 3A or 3 B

If your child has no response to Stage 2 then the Child Bipolar medication guidelines suggest either trying a third monotherapy agent (3A).

or

Combining two agents (3B).

Stage 4A

If the the choie was made to try a third montherapy agent and the child does not respond or there is a partial response,the next choice would be to use combination treatment.

Stage 4B

If 4A produces no or partial response then it is recommended that 2 mood stabilizers be tried with an atypical antipsychotic.

Stage 4B

If the choice was made to skip the third trial of a monotherapy agent and to try combination treatment and that does not work, then it is also recommended that two mood stabilizers and an atypical antipsychotic be tried.

Stage 5

If two mood stabilizers and an atypical antipsychotic are tried and there is no response then alternative monotherapy is recommended (i.e. Geodon or Tripleptal)

Stage 6

If that does not work than ECT is recommended for adolescents or Clozapine.

BIPOLAR I DISORDER, MANIC OR MIXED WITH PSYCHOSIS.

Stage 1

Mood Stabilizer + Antipsychotic

The first choice if your child has this diagnosis is a mood stabilizer plus an antipsychotic from the list above.

Stage 1A Augmentation or 3 Medications

If your child has a partial response then the Child Bipolar medication guidelines suggest adding another medication from above.

Stage 2 New Combination

If your child had no response or did not tolerate the first Stage 1 combination then the guidelines suggest trying a different combination of mood stabilizer and antipsychotic.

Stage 2A Augmentation

If your child responded partially to Stage 2, then the combination should be augmented with an additional mood stabilizer or antipsychotic.

Stage 3

If your child did not respond to Stage 2 then it is recommended that an alternate antipsychotic be tried.

Stage 3A

If your child had no response to the augmentation in Stage 1A or Stage 2A then the Child Bipolar medication guidelines suggest trying an alternate antipsychotic.

Stage 4

If your child has no response in Stage 3, or a partial response, then the bipolar medication guidelines suggest trying two mood stabilizers and an atypical antipsychotic).

Stage5

If your child has not response in Stage 4 or in Stage 3A then the guidelines recommend monotherapy with Trileptal or Geodon plus another antipsychotic.

Stage 6

If that does not work than ECT is recommended for adolescents or Clozapine.

Axelson D, Birmaher B, Strober M, et al. Phenomenology of children and adolescents with bipolar spectrum disorders. Arch Gen Psychiatry. 2006;63:1139-1148.

Kowatch RA, Fristad MA, Birmaher B, Wagner KD, Findling RL, Hellander M, Child Psychiatric Workgroup Members. Treatment guidelines for children and adolescents with bipolar disorder: Child Psychiatric Workgroup on Bipolar Disorder. J Am Acad Child Adolesc Psychiatry. 2005;44:213-235. 



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