My Experience With Mania, Bipolar Disorder
What is the treatment approach for children and adolescents?
The treatment of children and adolescents must first begin with a comprehensive evaluation by a qualified practitioner. Find a treatment provider who has experience with this population or better yet has specialty training with this population. The evaluation tends to encompass more areas of query than do adult evaluations, with full developmental history and family history obtained, and school functioning assessed and contrasted with home functioning. As in adults, other conditions must be considered and ruled out before diagnosing a mood disorder. Once bipolar disorder has been diagnosed, a treatment plan should address the following needs:
• Individual
• Medical
• Family
• School
• Legal
Individual needs can be addressed with psychotherapy.
Cognitive-behavioral and interpersonal therapy approaches have been studied and found effective in adolescent depression. Children and adolescents can benefit from other psychotherapeutic approaches as well. Group therapy should be considered if there are concerns about social development. In addition to individual psychotherapy, work with children and adolescents often needs some level of family work, either with the parents or including siblings as well? Because a child is a member of a family system, the dynamics between the child and others may need to be addressed in ways that individual work cannot. Problems with behavior may require enhancement of parenting skills. Psycho education of family members too may be needed to help them understand the patient’s illness.
Medically, a decision is to be made regarding the use of somatic treatments for bipolar disorder in a child or adolescent, such as a mood stabilizer. Due to the severity of untreated bipolar disorder, a medication will likely be recommended in addition to therapy. All children and adolescents should have medical clearance through the pediatrician to rule out any underlying medical conditions.
Baseline laboratory studies will be needed. Educational needs are also assessed in children and adolescents. A child with bipolar disorder needs and is entitled to accommodations in school. Bipolar disorder and the medications used to treat it can affect a child’s school attendance, alertness and concentration, motivation, and energy available for learning. Functioning can vary greatly at different times throughout the school year. Recurrence of depressive and manic episodes can cause academic delays and may be associated with comorbid learning disabilities. A board of education assessment will determine the most appropriate educational setting. The educational needs of a particular child with bipolar disorder vary depending on the frequency, severity, and duration of episodes of illness. Most states mandate that appropriate educational services be made available to minors with emotional and/or behavioral problems, which may consist of smaller classroom settings, non-public school placement, day treatment programs, or even residential treatment settings.
Legal needs of a child also have to be considered in the evaluation process. As the child is a minor, a parent or guardian will make the final decision regarding the treatment intervention. Older adolescents do, however, have some say about their treatment. In particular, it is best if they are in agreement to a medication because they cannot be forced to take a medication against their will. Other legal issues to consider are custody issues and need for family court involvement or state involvement.
What are the risks of treating my teenager with psychotropic medication?
In years past, it was often presumed that medications worked in young people the same as in adults. Clinical trials rarely included persons under the age of 18. Prior to the development of SSRIs, children and adolescents were rarely treated with antidepressants. The tricyclics and monoamine oxidase inhibitors that were available had potentially harmful side effect profiles that outweighed the benefit of the treatment. This was in part because clinical studies in persons under 18 did not demonstrate antidepressants to be more effective than placebo. When SSRIs entered the market, however, because of their better safety profile, prescriptions for antidepressants in children and adolescents increased dramatically. There was clearly a need for safe, effective treatments, because in adults untreated depression has serious adverse outcomes. In recent years, studies of SSRIs have been conducted in children and adolescent populations, with efficacy demonstrated in some. One observation from SSRI studies (that was also noted in the early studies using tricyclics) was the presence of a relatively high placebo response rate. Adolescents may benefit from the supportive contact with the treatment provider and thus “respond” to the placebo. Talk therapy is clearly a necessary part of treating depression in children and adolescents, even if on medication.
In the treatment of bipolar disorder, medication use is more complicated due to the potential need for more than one medication. In addition, except for the use of Sarafem (fluoxetine) for major depression, no medication indicated for a mood disorder (depression or bipolar) in adults has such an indication for use in children or adolescents. Some antidepressants, for example, while effective in adults have data that do not support their efficacy in children and adolescents.
Although the FDA has not provided indications for use of medications in youth with bipolar disorder, because of the significant risks of no medication intervention, it is standard practice to treat the condition with medications that have demonstrated efficacy in adults. Many medications have some level of research evidence in literature supporting their use in childhood bipolar disorder, but their use is considered “off-label.” Monitoring of medication therapy must be done very closely.
In the case of using various mood stabilizers other than antidepressants, choices become more difficult due to the increased severity of side effects in contrast to SSRI antidepressants. Children and adolescents appear to be more sensitive to the side effect of weight gain, for example, which can significantly hamper compliance as well as contribute to physical health problems. Lithium has been studied in children for a variety of conditions. Adverse effects are similar as in adults, with careful monitoring of kidney and thyroid function required. Regular blood level monitoring is necessary as well because of the narrow range between effective blood level and toxic blood level. Studies in patients with epilepsy have shown that Depakote (valproate) may increase testosterone levels in teenage girls and produce polycystic ovary syndrome in women who begin taking the medication before age 20 (Question 79). Therefore, young female patients taking Depakote (valproate) should be monitored carefully by a physician.
There have been recent concerns about the risk for increased suicidal thinking in children and adolescents prescribed SSRIs. Warnings are now included in the labeling of all antidepressants that there can be a risk of suicidality, and close monitoring is recommended. It is not clear, however, if such effects are specific to certain SSRIs. A recent analysis by the FDA of all the studies of newer antidepressants showed a rate of suicidal behaviors in 3% to 4% of children and adolescents with depression who took an antidepressant and a rate of 1% to 2% of those taking a placebo (inactive pill). Of note, there were no deaths by suicide in any of the studies. Also, there was no difference in the rate of suicidal behavior for those being treated with an antidepressant for an anxiety disorder. The results of the analysis have prompted the FDA to require a warning on all antidepressants regarding the risk of increased suicidal behavior (thoughts or actions) when used in children and adolescents. While this can be disconcerting for any parent, it is important to keep in mind that the risk for suicide in untreated depression is approximately 15%.. The necessity for close monitoring is important because of this. As in adults, depression is a condition that is associated with suicidality. Whether on an antidepressant or not, patients need to be closely monitored for the onset of such symptoms or worsening of existing symptoms. Keeping the data in mind, contrary to fears of increased suicidal tendencies, data from around the world actually document that the suicide rate among teenagers has dropped concordant with increased prescribing of SSRIs for depression.
I have been hearing about polycystic ovaries.What is that and should I be concerned if I take Depakote (valproate)?
Polycystic ovary syndrome, also known as PCOS, is a syndrome that includes a cluster of signs and symptoms usually associated with having polycystic ovaries. A polycystic ovary is defined by having at least ten ovarian cysts. Not all women with polycystic ovaries develop PCOS and not all women with PCOS have polycystic ovaries. The signs and symptoms may include polycystic ovaries, menstrual cycle irregularities (both frequency and flow), excessive body and facial hair (hirsutism), female-patterned baldness, and skin problems, including acne. All of these signs and symptoms stem from hormonal imbalances, which include an overproduction of testosterone. Additionally, truncal obesity and metabolic syndrome may accompany the signs and symptoms described above. The prevalence of PCOS varies depending upon the researchers’ definition but ranges anywhere from 4% to 18%. PCOS does appear to occur more often in women with epilepsy than others, with rates between 13% and 25%. It also appears to occur more frequently in women with bipolar disorder, though in frequencies less than in those with epilepsy. Menstrual irregularities have been shown to approach 50% in women with bipolar disorder independent of treatment. One explanation as to why women with either epilepsy or bipolar disorder may have more frequent menstrual irregularities, as well as PCOS, may have to do with the brain’s poor regulation of the endocrine system secondary to seizures or manic-depressive cycles.
Not only is it believed that these conditions may cause PCOS, it may be the case that PCOS worsens these conditions through the hormonal imbalance PCOS causes. The question of whether or not PCOS is caused by anticonvulsant medications, especially valproic acid, has been hotly debated, though current research suggests that valproic acid does increase the chance of developing it. This research has suffered from the fact that few, if any, longitudinal studies following women over a long course of therapy have been done. That being said, the increased risk is particularly evident in young teenage women. The mechanism by which Depakote (valproate) may increase risk is poorly understood but may be attributed to a number of factors.
Depakote (valproate) appears to affect hormone levels independently, which may in turn contribute to PCOS. Depakote (valproate) is not enzyme inducing and therefore will not reduce hormones that promote PCOS as other anticonvulsants will do, such as Equetro (carbamazepine), phenytoin, and Lamictal (lamotrigine). In fact, the latter two anticonvulsants appear to reverse PCOS in women who develop it while on Depakote (valproate). Finally, Depakote (valproate) causes weight gain, which is associated with higher circulating levels of insulin and male hormones, both being linked to PCOS. It is difficult to determine diagnostically whether or not one has PCOS as there are different definitions of the syndrome and no one test can clinch the diagnosis. As a result it remains a diagnosis of exclusion. The simplest approach in management of PCOS is to treat the symptoms empirically.
That is, if there is a strong possibility it is developing or has developed; switching medication is the first line of treatment.
Terms:
Somatic – referring to the body.
Somatic therapy – refers to all treatments that have direct physiological effects, such as medication and ECT.
Somatic complaints – refer to all physical complaints that refer to the body, such as aches and pains.
