Aggression mood stabilizers

When these measures have failed and impulsivity and aggression remain a problem, additional strategies are available. First, reconsider the diagnosis. Does the patient have bipolar disorder rather than ADHD Is there another disruptive behavior disorder in addition to or instead of ADHD Does (s)he have an impulse control disorder In these more severe cases, other medications such as atypical antipsychot-ics or mood stabilizers are often helpful. 

When stimulants cannot be used, clonidine or antidepressants are the best initial treatments for impulsivity. As noted earlier, more aggressive measures including antipsychotics and mood stabilizers may be needed in severe cases. 

In the Expert Consensus survey (Rush and Frances, 2000), respondents were asked to rate which classes of medication may be helpful for treating patients with severe and persistent physical aggression and those who destroyed property. The atypical antipsychotics were rated most highly, followed by anticonvulsant/ mood stabilizer. These were followed (with much lower priority) by antidepressants and beta-blockers. Among the atypical antipsychotics, risperidone was rated most highly, followed by olanzapine others had much lower ratings. Divalproex or valproic acid and carbamazepine were rated highest of the mood stabi-... 

No specific antiaggressive agent exists for children. Flowever, antipsychotics, anticonvulsants, mood stabilizers, antidepressants, sedative-anxiolytics, and beta-blockers are all used to target aggression. Unfortunately, few controlled studies exist that assess these agents. 

On a slightly more positive note, combination treatments, such as combined mood stabilizers or mood stabilizer plus antidepressant, may decrease relapse rates early, aggressive intervention may shorten subsequent episodes and newer agents, such as VPA, CBZ, or lamotrigine may benefit previously resistant subgroups of bipolar disorders. It is also encouraging that patients in good remission on lithium often view themselves favorably compared with normal control subjects on life satisfaction and adjustment measures. 

At this time, the preferred first-line drug therapy for ADHD is either methylphenidate, dexmethylphenidate, mixed amphetamine salts, or dextroamphetamine. Atomoxetine, bupropion, or TCAs are good options for those umesponsive to or unable to tolerate stimulants. Clonidine and guanfacine are third-line options or adjuncts that require careful cardiovascular monitoring. Mood stabilizers (e.g., lithium, divalproex, and carbamazepine) and atypical antipsychotics are adjuncts for control of aggression or comorbid bipolar disorder. Other agents require further investigation before their status in the treatment of ADHD can be fuUy determined. 

Klonopin (clonazepam) A conunon medication used as a mood stabilizer often prescribed for the following reasons inadequate response or intolerance to antipsychotics or lithium, manic symptoms, rapid cycling of the condition, EEC abnormalities, and head trauma. The most common side effects are difficulty with balance and drowsiness. Behavioral and emotional side effects include irritability, excitement, increased anger and aggression, trouble sleeping or nightmares, and memory loss. The most serious side effect is the interaction effect if this medication is combined with alcohol or other drugs, which can result in sleepiness, unconsciousness, and death. 

In addition to its use in mood disorders, lithium has been suggested or examined in a wide range of neuropsychiatric conditions. Lithium is one of the pharmaceuticals that is frequently recommended for the management of aggressive behavior independent of diagnosis. In a review of 16 published studies, 7 or 8 (depending on definition of response) were foxmd to be positive [43" " ], and indeed, it appears to reduce impulsive behavior in rats—a characteristic not shared by tire otiier common mood stabilizers, carbamazepine, or valproate [44an nia> study]... 

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