Adolescents bipolar disorder

Adolescent bipolar disorder (BD) was described in the early twentieth century writings of Kraeplin, who noted a significant emergence of BD at puberty (Kraeplin, 1921). It is only within the past decade, however, that adolescent-onset BD has begun to receive significant research attention. Studies estimate the prevalence of bipolar spectrum disorders (e.g., bipolar I, bipolar II, bipolar not otherwise specified) as being 1% in adolescents (Lewinsohn et ah, 1995). In addition, it is estimated that 20%-40% of adults with BD experi-... 

Geller, B. and Luby, J. (1997) Child and adolescent bipolar disorder a review of the past 10 years. / Am Acad Child Adolesc Psychiatry 36 1168-1176. 

Geller, B., Cooper, T.B., Sun, K., Zimerman, B., Frazier, J., Williams, M., and Heath, J. (1998a) Double-blind and placebo-controlled study of lithium for adolescent bipolar disorders with secondary substance dependency. / Am Acad Child Adoles Psychiatry 37 171-178. 

Because CBZ and valproate have been used for many years to treat seizure disorders in children and adolescents, more systematic knowledge about their clinical pharmacology in this age group is available than there is about lithium. However, pediatric patients with epilepsy are often on concomitant therapy with other anticonvulsants. That fact complicates attempts to extrapolate from this experience to the use of CBZ or valproate as monotherapy for childhood or adolescent bipolar disorder. For example, the risk of serious and potentially fatal hepatotoxicity with valproate occurs almost exclusively in children younger than age 10 years (usually 2 years or younger) who are on multiple anticonvulsants for congenital seizure disorders. How or whether this risk translates to children or adolescents who are on monotherapy with valproate for bipolar disorder is unknown. Nonetheless, clinicians need to be aware of this possible risk and take the following steps to increase the likelihood of early detection in case this problem arises ... 

Personality disorders are inflexible and maladaptive patterns of behavior that deviate markedly from expectations of society. These patterns are stable over time, pervasive and rigid, and lead to distress or impairment in the individual s life. Onset is in adolescence or early adulthood.1 Personality disorders and bipolar disorder may be comorbid, and patients with personality disorders may have mood symptoms. The two diagnoses are distinguished, however, by the predominance of mood symptoms and the episodic course of bipolar disorder, in contrast to the stability and persistence of the behavioral patterns of personality disorders. 

Kowatch RA, Fristad M, Birmaher B, et al. Treatment guidelines for children and adolescents with bipolar disorder. J Am Acad Child Adolesc Psychiatry 2005 44 213-235. 

Two or more major depressive episodes Manic episode major depressive or mixed episode Major depressive episode + hypomanic episode Chronic subsyndromal depressive episodes Chronic fluctuations between subsyndromal depressive and hypomanic episodes (2 years for adults and 1 year for children and adolescents) Mood states do not meet criteria for any specific bipolar disorder... 

Weller EB, Calvert SM, Weller RA. Bipolar disorder in children and adolescents diagnosis and treatment. Curr Opin Psychiatry 2003 16(4) 383-388. 

Utility of Preclinical Models in Organizing Findings of the Neurobiology of Bipolar Disorder in Children and Adolescents... 

Preliminaty Results of Neuroimaging Studies in Children and Adolescents with Bipolar Disorder... 

Blumberg, H., Kaufman, J., Martin, A., and Peterson, B. (2001) Structural and functional MRI studies in children, adolescents, and adults with bipolar disorder. Presented at the Childhood Depression A Critical Review Conference. Banbury Center, NY Cold Spring Harbor Laboratory. 

Dasari, M., Friedman, L., Jesberger, J., Stuve, T.A., Findling, R.L., Swales, T.P., and Schulz, S.C. (1999) A magnetic resonance imaging study of thalamic area in adolescent patients with either schizophrenia or bipolar disorder as compared to healthy controls. Psychiatry Res 91 155-162. 

Kowatch, R.A., Suppes, T., Carmody, T.J., Bucci, J.P., Hume, J.H., Kromelis, M., Emslie, G.J., Weinberg, W.A., and Rush, A.J. (2000) Effect size of lithium, divalproex sodium, and carbama-zepine in children and adolescents with bipolar disorder. / Am Acad Child Adolesc Psychiatry 39 713-720. 

Lewinsohn, P.M., Klein, D.N., and Seeley, J.R. (1995) Bipolar disorder in a community sample of older adolescents prevalence, phenomenology, comorbidity and course./ Am Acad Child Adolesc Psychiatry 34 454-463. 

Mania. Mania and hypomania can also occur in children and adolescents on SSRIs, and, again, it is not known if there is an added developmental risk (Ven-kataraman et al., 1992). In a fluoxetine treatment study for depression, 3 (of 48) patients developed manic symptoms, even after excluding patients with psychotic depression, bipolar symptoms, or a family history of bipolar disorder (Emslie et al., 1997). In a paroxetine treatment study for depression, 5 adolescents (of 93) were removed for emotional lability and 1 for eupho-ria/expansive mood (Keller et al., 2001). 

Frazier, J.A., Meyer, M.C., Biederman, J., Wozniak, J., Wilens, T.E., Spencer, T.J.,Kim, G.S., and Shapiro, S. (1999) Risperidone treatment for juvenile bipolar disorder a retrospective chart review./ Am Acad Child Adolesc Psychiatry 38 960-965. 

There is no empirical evidence available for clinical use in children and adolescents. Yet, Hypericum seems to be used for the treatment of mild to moderate depression in the young (Walter et ah, 2000). St. John s wort should be avoided in young patients with severe depression and bipolar disorder (given the lack of adult data about effectiveness and risk of manic induction, respectively) and in those who have significant suicide risk. Treatments of proven efficacy (e.g., SSRIs, mood stabilisers) should be preferred in these cases. However, St. John s wort may be considered in cases of unipolar depression where conventional treatments have failed and prior to the use of combinations of drugs that have an increased risk of side effects and whose efficacy has not been demonstrated. 

The primary indication for ECT in adolescents is the short-term treatment of mood symptoms, depressive or manic (Walter et al., 1999). Mood symptoms in the course of major depression, psychotic depression, bipolar disorder, organic mood disorders, schizophrenia, and schizoaffective disorder respond well to ECT. Psychotic symptoms in mood disorders also respond well to ECT whereas the effectiveness of ECT in the treatment of psychotic symptoms in schizophrenia is doubtful. There are suggestions that other uncommon clinical conditions in adolescents such as catatonia and neuroleptic malignant syndrome also benefit from ECT. The effectiveness of ECT seems to lessen when there is a comorbid personality disorder or drug and/or alcohol problems. There are very few data about usefulness on prepubertal children. 

Mania/bipolar disorder 1. Parent and teacher 2. Sitter, after-school director, coach, scout leader, bus driver. 3. Child 1. Parent and teacher 2. Adolescent 3. Coach, employer... 

Wozniak, J., Biedetman, J., Kiely, K., Ablon, S., Fata one, S., Mundy, E., and Mennin, D. (1995) Mania-like symptoms suggestive of childhood onset bipolar disorder in clinically referred children. J Am Acad Child Adolesc Psychiatry 34 867-876. 

Many of the children and adolescents seen for treatment of depression are experiencing their first depressive episode. Because the symptoms of unipolar and bipolar depression are similar, it is difficult to decide whether a patient needs only an antidepressant or concomitant use of mood stabilizers. As noted above, symptoms and signs such as psychosis, psychomotor retardation, or family history of bipolar disorder may warn the clinician about the risk of the child developing a manic episode. 

Chart reviews and open trials of outpatients with bipolar disorder and bipolar spectrum disorder have been published for 28 risperidone- and 23 olanzapine-treated treated children and adolescents (Frazier et ah, 1999 2001). Significant decreases in mania, depression, and aggression ratings occurred over the course of treatment however, other medications were also used simultaneously. Additional anecdotal information exists for olanzapine (Soutullo et ah, 1999 Chang and Ketter, 2000), quetiapine (Schaller and Behar, 1999), and clozapine (Fuchs, 1994). 

Carlson, G.A. (2000) Very early onset bipolar disorder. Does it Exist in Childhood In Rapoport, J, ed. Onset of Adult Psychopathology—Clinical and Research Advances. APPI Press, pp. 303-332. Carlson, G.A., Bromet, E.J., and Lavelle, J. (1999) Medication treatment in adolescents vs adults with psychotic mania. / Child Adolesc Psychopharmacol 9 221-231. 

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