PharmaTherapy

The latest trends in mental-health medication management for consumers, professionals, and caregivers.

Medicating Children with Bipolar Disorder

What should come first - safety or effectiveness?

When it comes to stabilizing and maintaining remission of the constellation of symptoms associated with bipolar disorder, clinicians often disagree over an appropriate course of action. This is particularly true for the use of mood stabilizers and antipsychotics to treat pediatric bipolar disorder, especially among young children.

There's little doubt that childhood bipolar disorder is being diagnosed more frequently than ever before. Office visits by children diagnosed with bipolar disorder multiplied 40-fold from 1994 to 2003, according to a recent article in the Archives of General Psychiatry. However, disagreements abound as to what this means. Some researchers view the trend as a sign of progress: A disorder that has long gone undiagnosed is now being better screened and treated. Others, however, are more skeptical; they perceive the trend to be an example of gross over-diagnosis, although their perceptions are not on firm scientific footing.

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In truth, childhood bipolar disorder is quite difficult to diagnose. Many of the disorder's characteristic symptoms overlap those of other disorders, particularly attention deficit/hyperactivity disorder (ADHD) and conduct disorder (CD). In fact, studies indicate that as many as 90 percent of all children with bipolar disorder also have ADHD, and that roughly 50 percent also have comorbid CD. Further complicating diagnosis, the presentation of childhood mania differs dramatically from that in adults. For example, in children and adolescents, the manic phase of the disorder tends toward extreme irritability and destructive outbursts, while in adults, the manic phase is more commonly expressed as grandiosity or euphoria. Also, the duration of these episodes in children is often too brief to satisfy diagnostic criteria.

The most widely used mood stabilizers for treating children and adolescents diagnosed with bipolar disorder are lithium and Depakote. Although studies confirm that these medications are effective, their safety is questionable, due to the life-long nature of bipolar disorder. Long-term lithium use has been linked to quite a few side effects, ranging from acne and cloudy thinking to weight gain, tremors, decreased thyroid function, and kidney problems. As a result, children taking lithium should have their blood levels monitored several times a year. Similarly, long-term use of Depakote can cause liver problems and toxicity. In fact, Depakote's potential health risks have led the FDA to order that a "black box" warning be placed on the medication for both pancreatitis and liver failure. For this reason, any child taking Depakote should have their blood tested every three to six months.

Second generation antipsychotics appear to be effective at managing the severe mood swings associated with bipolar disorder in children and teens. But again, benefit-vs.-risk is a considerable concern. These drugs can induce weight gain, sleepiness, parkinsonian and extrapyramidal symptoms, elevated lipid levels, and an increased risk of developing Type II diabetes. As a result, only two of these antipsychotics -- Risperdal and Abilify - have been FDA-approved for use with children. Three others -- Seroquel, Geodon and Zyprexa -- are now under the FDA's consideration for use with children.

Looking ahead, the safety/effectiveness conundrum associated with mood stabilizers and newer antipsychotics in the treatment of pediatric bipolar disorder will most likely linger until a new, safer generation of compounds is developed. When it comes to treating children, the balance needs to favor minimizing risks. However, for children with serious and potentially dangerous behavioral problems associated with bipolar disorder, the benefits of medication use typically far outweigh these risks.

Joe Wegmann is a licensed pharmacist and clinical social worker, professional speaker and trainer, and the author of Psychopharmacology: Straight Talk on Mental Health Medications.

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