by James Chandler, MD, FRCPC
The bipolar disorders are mood disorders. That means that amongst other things, there is a major change in mood. In bipolar disorders, this change in mood can be down, as in depression, or the opposite, mania. That is, a person can be inappropriately up. Some types of bipolar disorder have a lot of depression and only a little mania. Others have half and half. Still others seem to be both manic and depressed at the same time. Some people with bipolar disorders only have a few cycles of depression and mania. Others have many cycles a year. When bipolar illness is present in children and adolescents, it is more severe and harder to treat than when it occurs in adults. Pediatric Bipolar illness is one of the most severe conditions in pediatrics. In the milder forms, it can be disabling. In the severe forms, it can be lethal. The prognosis for cancers in pediatrics is better than many forms of bipolar illness.
All bipolar disorders are a combination of mania with or without depression. So what is mania? Here are the official criteria:
An elevated, expansive, or irritable mood, lasting at least 1 week. This mood is also accompanied by at least three (four if mood is only irritable) of the following:
1. Inflated self -esteem or grandiosity
2. Decreased need for sleep
3. Increased talkativeness or pressure to keep talking
4. Racing thoughts or flight of ideas
6. Increased Activity or psychomotor agitation
7. Excessive involvement in pleasurable activities that have a high potential for painful consequences.
The disturbance should be so severe that hospitalization is required to avoid harming themselves or others.
In pediatric mania and Hypomania, the mood is more likely irritability. these features often come and go throughout the day and are not as persistent as in adults.
Mania - Justin
Justin is 11 years old. He is usually a hyperactive boy who does okay in school, but not without a lot of help from teachers and his family. His mother, Christine, first wondered what was going on April 3. The teacher called saying she had to send Justin to the Principal's office twice that day. When Justin came home he zoomed inside, threw his book bag at the door, and shouted something about a great idea. She came outside to watch as her son leaped from the top of the house to a bush with his arms holding a big piece of plywood. By the grace of God, he was not hurt. When she asked what he was doing, she got some answer about space shuttles and landing pads. She took the board and told him to go inside. He punched her in the stomach and said, "no way, bitch" and went off on his bike. She had never seen her son like this. Over the next three days, life became unbearable. He was thrown off the bus, wrecked his bike, nearly burned down the house making pancakes at , and called his friends in the middle of the night when his parents were sleeping. He shaved pieces of his hair off, drank four cans of beer out of the refrigerator, and finally ended up jumping up and down on top of an RCMP car before he was brought to hospital.
Sarah is 12 years old. She has been depressed for about 6 months. She isn't suicidal, but she just lays around, is more irritable, and does worse at school than before. She has let a lot of her friendships go and the only thing that still gets her excited is when her cousin down the road visits. Over the last few days Sarah started to finally come out of her slump or depression. She started calling old friends, went back to playing the piano, and seemed more interested in her school work. It was last Friday that they noticed the giggling was more than usual. She called about ten friends to see if they could come over and most did. They started playing a game, and then Sarah started to giggle and come up with new rules and make all sorts of jokes, only a few of which were funny. Sarah thought they were all funny. She put her socks on her ears and started dancing around the room. Her friends didn't think it was funny, and then Sarah got mad and told them to all go home. The weekend was rough. Her parents were awakened to piano playing throughout the night and every hour or so she would zoom in to tell them something she forgot to tell them earlier. Except it was so mixed up with giggling, you couldn't tell what she was talking about. Discipline made no difference. On the next day of school, Monday, the principal called her Dad at the garage to have him pick her up. She was disrupting the whole class and acting like a two year old. She was laughing, but no one else was. They brought Sarah home and basically watched her 24 hours a day for 2 weeks. Her mom had to take a leave from work. Eventually she slowed down and returned to her usual depressed self. It took months before her old friends would have anything to do with her.
Hypomania - Alex
Alex is 13. He has been a tough child to raise from infancy. He has always been aggressive and very active. By the time he got to school, he had already been seen by a pediatric psychiatrist and diagnosed with ADHD. Except for 5th grade, he passed every year with the help of a flexible program, medications, and a devoted family. Luckily, he hadn't been in much big trouble, until now. A week ago Alex took off. He was mad at his Dad about some trivial matter, threw a plate at him and headed into town on foot. A week later the RCMP called saying they had, after a major search, found the child. According to their reports, he had broken into two houses, and stolen about 3 quarts of rum in each home. He had drank that and smoked all the cigarettes he had stolen, too. Another boy who was also involved went to the police as he thought Alex was going crazy. Alex was running around the camp they were staying in all night long shouting and screaming songs from a CD he had. When the RCMP arrived, Alex was overly friendly, talking a mile a minute, and wanted them to listen to this CD. He then said, "Catch me Pigs" and took off into the woods. It took them another hour to catch him. After staying at home for a couple of days, he slowly came back to his old self, except he was depressed. He couldn't understand why he had done these things. No one else could either. He is still on probation a year later and some of his old friend's parents still won't let their children hang out with Alex.
Mania with Psychosis - Neal
Mania or Hypomania can also come with psychosis. Psychosis is the word to describe hallucinations, paranoia, and bizarre thoughts. Here is an example of that.
Neal is 13. Neal had an episode of depression a year ago where he did not want to do any sports at all and just sat around at home. He gained 10 lb. and spent most of his time in his room playing video games. He barely was passing in school and was a hard guy to live with. This was totally out of character. Neal was not an inside guy. He was usually outside building something, snaring rabbits, playing ball in the summer, soccer in the fall, and playing hockey in the winter, when he and his parents could afford it. He was turning out to be a real asset on his Dad's boat this lobster season and the other fisherman at the wharf often commented on what a fine young man Neal was becoming. Until a month ago. It started with not sleeping and racing their four wheeler. He smashed it and didn't seem too worried at all. When his father approached him about this, he told his father off and walked off. He got in fights at school for the first time in his life. He started wearing only purple clothes. Why? Because, he was "King". At first it was like a joke the way he treated everyone like subjects. Then it wasn't. Especially when he would not eat for two days because he had heard, through the TV, that the food was being poisoned. He then locked himself in his Dad's truck and talked to his "Judos" (his made up word) for half the evening. When the RCMP came, he finally came out, telling his parents how all this was foretold in the Bible. They brought him to the hospital.
Usually a child will show episodes of depression before he or she shows episodes of mania. Sometimes the depression comes 3-4 years earlier. One common question is whether or not you can tell depression that is going to turn into bipolar disorder from the kind of depression that will never result in mania.
In other words, can you tell when there is just depression or whether you will have a child with Tony's problems or Shawna's?
Tony Bipolar depression
When Tony was 8 he had a rough, rough winter. He did poorly in school, was very crabby, and had trouble sleeping. He kept saying he hated school and he was always saying how dumb he was. Well, spring came and the “old Tony" came back. His parents basically forgot about it until he was 11. The same thing happened that year, but this time in the spring. This time he told his mom he was going to run away and he quit soccer, which was quite strange. But by the time school got out he was fine once again. Then at age 13, he got depressed and cut his wrists after he got caught smoking at school. He ended up going to the doctor. She decided to put him on Paxil, a depression medication. He took it for a week. By the end of the week he was no longer depressed. After another week he was talking back to the teachers, pulling girl's bra straps, and pushing down his little brother. He stopped sleeping altogether and nearly killed himself climbing on some old wharves. He started dancing (at ) to some heavy metal music and when they came up he had painted latex housepaint in splotches all over him and the walls. The next morning they were at the doctor's, who confirmed that he was now manic. The Paxil was stopped, other medications were started, but by the time he was 16 he had had more episodes than anyone really cared to count.
Shawna non-bipolar depression.
Shawna was depressed at age 8, 11, 15, 17, and most of her 20s. Every time the psychiatrists asked her about signs of mania, she would say, Ď only wish!
There are some signs and symptoms that suggest that depression may be the beginning of bipolar disorder. If a child has all of them, I would probably not give an antidepressant (these antidepressants can make you manic - click here for more information on this in the depression handout). If a child had a few of these signs I would suspect the beginnings of bipolar disorder.
Very slowed down movements
Feeling like you are made of lead
Too much sleeping
Hallucinations or strange beliefs in the past
Family history of bipolar disorder
For more information on bipolar depression, see the depression handout. click here for that link.
The type of Bipolar illness is determined by the combination of mania or Hypomania and either mild or severe depression. It is also determined by how fast the cycling is. That is, how often do they have an episode in a year?
Bipolar I Disorder - Children with this disorder have episodes of mania and episodes of depression. Sometimes there are fairly longer periods of normality between the episodes. Usually people spend much more time depressed than Manic. However, some children will have chronic Mania and rarely get depressed.
Bipolar II Disorder - Here people mostly have depression and occasionally have an episode of Hypomania, but not mania. Most people with this have long episodes of depression and virtually no time of wellness.
Cyclothymia - this variant is characterized by many episodes of Hypomania and occasional episodes of mild depression only. A child may have quite a few episodes of Hypomania over the span of a year.
Mixed states - In these conditions, a child will show signs of depression and mania at the same time. Most often, the mood is depressed and there are thoughts of suicide and hopelessness. The rest of the picture is however mania.
Rapid cycling Bipolar illness - This means there are many cycles of mania and depression each year.
Childhood Onset Bipolar Disorder - Children with this picture have episodes of mania and depression just like adult bipolar disorder but they are two differences.
Rene - 13 year old with rapid cycling
Rene has always been a handful. She was actually treated with Ritalin in grade 2, but hasn’t taken it since. When she got to sixth grade she started to get a little moody but her parents figured that was to be expected. However this year in grade 7 it is beyond moodiness. Rene has become totally unpredictable. She may come storming into the kitchen in the morning in a horrible mood, crying about how her friends are mean to her and never come over when she calls. She will be banging the cereal bowls around, refuse to eat what she pours because it looks so gross and then go back to her room , kick a few things, and leave for school. Her brother, age 15, then figures it is safe to come downstairs. Sadly, Rene's mom has to agree, yes now it is safe. This is how most days go lately. About once a week she gets thrown out of school for something. It doesn’t faze her in the slightest. Then all of a sudden she will come rolling in giggling, jumping around and telling all sorts of stories she has made up. They are really funny to her, but no one else. She goes around making silly noises and laughs at them. Her friends first thought she was on drugs. Then they laughed at her. Now they just stay away. However all this is nothing compared to what her brother calls "the Bomb". "the Bomb" is when Rene loses her temper. She always had a stubborn streak, but nothing like this. When he sees it starting, he goes out and doesn’t come back for a few hours. In the meantime Rene is a monster. She screams at everyone loud enough to make your ears hurt. If you try to go near her she will come after you. She pounds on the wall and slams the doors so hard the house just shudders. Lately, she has been tearing up her clothes during these. Twice the RCMP have come. Once when Rene's parents called and once when the neighbors did. Each time they decided it was safer to just let her be. As Rene's brother said, "Yeah, safer for the RCMP!". When these are over she is tired, still mad, and it takes a few hours for her to recover. Then she is back to her erratic self. But today is not actually one of those days. Rene walks right out of math class without saying anything and goes to the guidance counselor who is meeting with someone. She walks right in. She starts complaining about something which he can't understand and then she just starts crying and doesn’t stop. Her mom and dad come and take her to the hospital emergency room, but by the time she gets there she is back to giggling about this fat lady in the waiting room.
Rene is a good example of someone who is very ill but has not really done anything too dangerous or risky.
Shawn -14 years old with classic childhood onset bipolar disorder which no one recognizes
When Shawn was four he was thrown out of preschool. Forever. He bit a girl so bad she had to be taken to the hospital. His mother was covered with bruises from the time he could kick. Shawn gave new meaning to the word violent. By the time he was in grade 1, dogs would run when they saw him and most kids would, too. He had set fire to two dogs and when he got mad he just threw anything. When he was 8 he threw a hammer through the front window of the house. By the time he was 10, when he had a "rage attack" as his father described them, they went in the house, got him outside, and locked the doors. In between his rages he was hyper and aggressive but with a lot of help from family they managed until he was 12. Then Shawn discovered drugs and alcohol. By the time he was 13 he was breaking into houses, drinking everything they had on the spot, and passing out. He would take anything. He had been in outpatients many a time with overdoses. Finally he was old enough to be sent away after breaking and entering too many times. He got to the Youth Prison and spent the first 30 days in the discipline unit. Why? He was just wild. Finally he calmed down enough one day for him to be brought to the psychiatrist. He was talking fast, irritable, thought he could beat up anyone and at the same time wanted to kill himself. Then while the doctor talked to his mother on the phone he started crying. When he left the office he was showing the secretary some new moves he had figured out which would get him into the WWF.
Shawn probably had bipolar disorder for some time, but no one thought of it.
Samantha - 13 years old with bipolar disorder which is detected almost too late.
Sam started to go through puberty at age 11 and by 12 she was looking like she was 15. At first she was moody, but no one thought much of it. She did fine in school and came from a nice family. She played in band, liked to write stories, and was on the Girl's basketball team. Everyone liked her. Then things changed after Christmas in 7th grade. She started to get wilder. She started hanging around with the 9th grade boys who did drugs. She started wearing clothes that were totally unlike her. Her mom found some notes she had written to some boys. They were pretty graphic. The poems she wrote were sexually explicit and violent. She tried smoking pot. She dropped out of everything and started hanging around downtown and lying to her parents. She became more and more irritable. One day she got in a fist fight at school over nothing. The neighbors found her in their shed with some high school guy and neither of them had anything on. Her parents grounded her but she escaped through the window to go to some wild party. The party was busted by the police for many reasons. Samantha was brought home and started trashing her room. It was then that Samantha's mom finally realized that this is exactly how her brother was as a teenager. Her brother had bipolar disorder. Maybe Samantha did, too.
Years ago it was thought that most people get bipolar illness for the first time in their twenties. However recent studies of adults with bipolar illness show something quite different. Half of these people had their first episode of bipolar illness before age 17. About 20 % had their first episode between 10 and 14 years of age. The most remarkable thing was that 10% had their first episode between ages 5 and 9. (18) It is very common to start having bipolar disorder as a child or teenager.
About 1 % of Adults have a type of bipolar illness. As a person's age goes down, the smaller the chance of bipolar illness. It is currently very unclear how common it is in children. Perhaps .5% is a good guess. In adults, Bipolar illness is more common in females. In children and adolescents, it is more common in males.
Genetic - This is a strongly genetic condition. If a child has two parents who have had mood disorders, nearly every child will have a mood disorder (either a type of depression or a type of mania). If one parent has a mood disorder, about a quarter of the children will get a mood disorder.
Drugs - a number of drugs can make a person manic or look like mania. Steroids (by mouth, not just inhalers) are the most common prescription cause. Street drugs can mimic mania. A few other rarely used medications can, too.
However, the most important one to be aware of are the antidepressant medications. The drugs used for depression can make some people manic or hypomanic. In a recent study of Prozac in children for depression, about 5-10 % switched to mania. These were children who had not had mania before.
Infections - in rare cases infections of the brain, AIDS, and a few other rare diseases can cause mania. This is very rare in otherwise well children.
Hormones - Too much thyroid hormone can make you manic. This is also very, very rare in children.
Other rare neurologic conditions - Strokes, Multiple Sclerosis, tumors, epilepsy, and a few other rare causes can cause mania in children.
There are two types of mistakes you can make in diagnosing any disease. You can think something is mania when it really is something else, for example, street drugs. Or you can think a disorder is something else when it is really mania.
Besides a complete history and physical and talking to everyone involved, it is often times necessary to do other tests. Urine drug screens, CAT scans of the head, and blood tests are often used. If there is no family history of a mood disorder, then I am more aggressive in finding other causes.
This is the hard part. Mania can look a lot like a few other psychiatric disorders. It can look like a Oppositional Defiant Disorder or Conduct disorder ( a personality characterized by persistent violation of the rights of other and their property). It can look like ADHD. Almost 90 % of children who get mania will also have ADHD. (See accompanying handouts for details on these) It can look like "stress". Mania can also look like schizophrenia, as 16-60 % of children with mania have psychotic features such as hallucinations or bizarre ideas. (24) Also mixed states and a rapid cycling picture are more common. These atypical features (for adults) can remind people of adult schizophrenia.
Usually by keeping two things in mind you can keep from missing mania. First, Conduct Disorders usually do not get suddenly ten times worse. Nor do they appear out of the blue over age 7. Second, mania is usually genetic. A strong family history of mood disorders, especially mania, makes me wonder about mania in any episode of wild and out of character behavior.
Co-morbid conditions are those that tend to run together. Diabetes and heart disease are a common example. In pediatric psychiatry, there is a huge amount of comorbidity. Bipolar disorders have a lot of co-morbidity. In fact, in children and younger adolescents, it is almost always preceded or accompanied by another disorder.
What this means is that a child who is destined to get a bipolar disorder usually will show another psychiatric disorder earlier in his life. By far the most common one is ADHD. Over 90% of children who get manic had ADHD before they got manic or hypomanic. On the other hand, most children with ADHD never get mania. Other problems like oppositional defiant disorder and Conduct disorder are also common in children who get manic. This makes it even harder at times to tell if a person has a bipolar disorder as many of the signs and symptoms are the same as in ADHD. However, in ADHD alone, the symptoms do not dramatically increase for no apparent reason.
Substance abuse is very common in teenagers with bipolar illness. About 65% of teenagers with severe mania were abusing substances at the time they became ill. This is even more likely if the also have ADHD or Conduct Disorder. Continuing to abuse substances is one of the most important predictors of a child getting ill again. (11)
Bipolar disorders by their very definition are not one time illnesses. One of the most common questions I am asked about children who have been hypomanic, depressed or manic is, will this happen again? The sad answer is probably yes. Between 20-30% of children who have severe depression will become manic later in their lives. This is more likely if the depression came on suddenly, included psychosis, and a family history of bipolar illness was present.
Pediatric bipolar illness is very severe and chronic. Almost all children will have another episode of mood disorder in their lives. Most will have another episode within the next five years. In fact, recent studies have shown that youths with Bipolar disorder spend about 70% of their childhood and adolescence with some signs of either depression, mania, or both. (24) A number of things can be helpful in predicting this, but none is more important than a history of prior mood disorders, especially mania. The longer you have been ill with bipolar disorder and the more episodes you have had, the more likely you are to get it again. In other words, the longer bipolar illness goes on, the harder it is to stop. Here are some slightly less important predictors
No family history, medical causes present for mania (like steroids), no other neuropsychiatric disorders, sudden onset of mania after a stressor, a history of good functioning before illness, and above all, no prior episodes.
A strong family history of pediatric onset mania, numerous other co-morbid psychiatric disorders, poor functioning before illness, rapid cycling, mixed mania and depression, and above all, a long history of bipolar illness.
Most of these factors can not be changed by doctors, families, or patients. However, keeping a bipolar disorder from recurring can be affected. That is why identification and treatment of bipolar illnesses is critical. The longer a child has bipolar illness, the more likely it is to go on and on.
This 14 year old would have a bout of depression followed by hypomania for a week, and then more depression for another 6-12 months, then another bout of hypomania. This girl appeared to have chronic depression that never responded to treatment until someone finally saw her during an episode of mild hypomania. Then she was finally treated for bipolar disorder.
Now 11, Christin had a mild episode of depression after his parents separated at age 7, and then was well until age 11, when he became very depressed, then manic. He has spent about 2 years of his life, or about 20%, psychiatrically ill.
The most common pattern which is missed is ADHD followed by mania and depression. this child had marked ADHD for his first 7 years of life. Then every year or so he has an episode of hypomania which lasts a week and is hard to distinguish from his baseline hyperactivity. Finally at age 12 he becomes depressed and is treated with antidepressants alone. This unfortunately leads to full blown mania and finally the correct diagnosis.
Ashley started having an episode of depression lasting a few months followed by an episode of hypomania lasting a few weeks. She had this cycle every two years, then every year, then every 6 months and is now constantly either manic or depressed. Luckily, medications worked wonders for her.
Jonathan never received any treatment until he was in a youth prison. Starting with ADHD, he developed chronic mania for two years, followed by an episode of depression with a life threatening suicide attempt.
Disability during episodes - if you are more than a little depressed or have any degree of mania, you just can't do much of what you should be doing at a certain age. A child will not get along with his family. His friends will be fewer and not exactly the best kind of kids. It will make other family members have trouble themselves as this is so hard to live with. It can split up parents. In older children, serious crimes or accidents can occur during mania. School is very difficult to continue.
Disability between episodes - When other children see a child who is manic or hypomanic, they don't forget it for a long time. These children are shunned once they are well and are not easily accepted back by their peers. Depression is also a problem. The irritability which often accompanies pediatric depression can burn out friendships for a long time, even after it is gone.
Self esteem and development- having multiple episodes of bipolar illness interrupts a child's normal psychological development. They end up in many ways immature for their age and in other ways older than their age because of all the suffering they have gone through. From the child's perspective, it is as if there is tornado going through their lives on a random basis. The child is willing to pick up the pieces and start over a couple of times, but after that, many will just give up and think or say, "what is the use of trying? It is all going to get wrecked before I get going by the next episode"
Suicide - Obviously the worst outcome is this. It is not uncommon. In pediatric bipolar illness, 20% will make a serious suicide attempt. There are no quality studies of pediatric completed suicides in bipolar illness. In adults, about 19% of those with bipolar illness commit suicide.
The aims of treatment are fourfold.
1. treating acute symptoms
2. prevention of relapse
3. reduction of long-term morbidity
4. promotion of long-term development and growth.
Each of these goals is achieved with a combination of different treatments. Here are the different types of treatments. Nearly every person with bipolar illness will need a number of different types of treatments.
Medications ideally should stop the cycling, stop mania, stop depression, and prevent new episodes of depression and mania with no side effects. Unfortunately, we are nowhere near close to this aim, even in adults.
Some medications are good for one thing and not another. For example, a drug might help mania, but not depression.
While there have been many excellent studies comparing medication to placebo in adults, there are very few in children. In fact, there have only been five. All of these were addressing manic symptoms. There has never been a controlled trial of any treatment for pediatric bipolar depression. (24).
In a nutshell,
About 50% of children improve significantly when they are given Second Generation Antipsychotics or Mood Stabilizers.
The Combination of both together may work better than either alone.
No drug has been found that is clearly the better than others.
Older Mood Stabilizers (Epival, Lithium, Tegretol)
These drugs change the chemical balance in the brain. When they are effective, hypomania or mania goes away. When they are effective, they also will reduce cycling and make a person less likely to become manic again. In some people they are also effective for depression. However, they are much more effective for mania than depression. So you could easily see the cycling stop and see the mania end, and have a child end up depressed.
We know these agents are effective in many adults with bipolar illness. They are less effective in pediatric bipolar illness. For example, adolescents who have bipolar illness and are prescribed lithium (and take it) will have a 37% chance of relapsing over the next 18 months. If they don't take the lithium, they have a 90% chance of relapsing. In severe cases of rapid cycling bipolar illness, these drugs are often used in combination. They can prevent suicide (click here to go to the details of this in the Suicide handout)
Although we refer to lithium as a drug, it is actually a naturally occurring element. In some places in the world it is present to a significant degree in the drinking water. It has been used in adults for bipolar illness for almost 40 years. Approximately 80% of adults with bipolar illness will respond. The response is less when there is a mixed picture or rapid cycling. In some children and adults, it can make a normal life possible again. This drug will often stop or reduce cycling, get rid of mania and hypomania, and sometimes get rid of depression, too. It is not clear exactly how it affects the different parts of the brain to accomplish this. However, it is not an easy to use drug. It has numerous side effects. It has been used in children for a number of years.
Nuisance side effects
Occasionally this drug can cause nausea, vomiting, diarrhea, shakiness, and balance problems.
Psychologically serious but medically non serious side effects
This drug can cause or worsen acne. It can cause weight gain. It can, in some cases cause bedwetting. It can cause or worsen psoriasis.
Medically serious side effects -
Lithium can damage the kidneys. The most common problem is that it makes a person produce lots of weak urine, so they need to urinate all the time. Other changes can also occur more rarely. To be used safely, blood tests for the kidneys and urine tests are done on a regular basis. With regular monitoring, these changes can almost always be detected before they become serious.
Lithium can affect the thyroid glands. It can make the thyroid gland reduce the amount of hormone it puts out. This is another thing that can be managed by monitoring blood tests. If it is severe, and the drug is helping a lot, then a person can be given thyroid pills.
Lithium, at high levels, can affect the brain. If a person has high levels of this drug in them, it can make them confused, cause coordination to be poor, and make thinking slower. For this reason, the level of the drug needs to be monitored regularly.
If you become dehydrated from the flu, diarrhea, or other causes, and you keep taking your lithium, your body will save it up and the level will go higher and higher. This is the main danger of this drug. Anyone who is taking this drug needs to talk to the prescribing physician if they are getting dehydrated so they can figure out what to do. Usually, the drug is stopped temporarily.
Certain drugs can make the amount of lithium in your blood go very high.
You should not take Lithium if you are planning on getting pregnant. It has been reported to cause certain defects in the heart of the fetus.
So why would you ever give this drug?
Lithium comes in a couple of forms and sizes. The dose is determined by the blood level. So you have to take it for a few days, then check the blood level, adjust the dose, and check the blood level again. Once the level is in the proper range, then it is usually only checked every month.
When the drug works, it is usually within 2 weeks for mania or 4-6 weeks for depression. However, sometimes it takes much longer to see the full effect. It is very cheap.
Annette is 14. She has been admitted for depression following a week of hypomania. She has had one previous admission for depression. Her pediatric psychiatrist wants to treat her depression without risking her switching into mania. So he feels Lithium is a good choice. Before he starts the drug, blood tests for kidney function and thyroid function are checked. She starts taking 150mg twice a day and after a few days of this it is increased to 300 mg twice a day. Four days later a blood level is checked. It is .4 . The level should be .8-1.0. The doctor increases the dose to 450 mg twice a day and checks a level in another five days. It is .9. Annette has a little nausea and a tiny bit of tremor, but otherwise has no side effects. After four weeks, she is still very depressed. An antidepressant, Paxil, is added. Over the next two weeks she recovers from her depression. For the first month, she gets her lithium level checked weekly. Then it is twice a month for a few months, then every month. After she has been on the drug 3 months, other lab tests are checked. Annette takes the drug for 6 months, but at that point feels that she no longer needs it and think it is causing her acne. Against everyone's advice, she stops it. One month later she is again hypomanic, but her acne is better.
This example points out the reality of Lithium use in pediatrics. The medical side effects are a breeze to manage compared to compliance issues. Many children with bipolar illness do not have a lot of insight into their illness. Frequently after a few months they become non-compliant. Usually it is for trivial reasons from an adult's perspective. The biggest problem with lithium is that people don't like to take it long term. In fact, a big part of the counseling for this disorder is devoted to just this issue.
suicidal urges, a bipolar disorder, family history of a good response to
lithium, and manic symptoms on an antidepressant,
This mood stabilizer has been used for years to treat epilepsy. Over the last five years it has been found to be very effective in bipolar illness in adults, especially in mixed bipolar illness and rapid cycling bipolar illness. It is not clear how this, or other anticonvulsant drugs, work for bipolar illness. It has been tested some, but not a whole lot, in pediatric bipolar illness.
Nuisance side effects
Occasionally this drug will cause nausea, tremor, vomiting, or diarrhea. It can be sedating in some people. It can affect balance. It can make a person temporarily lose some of their hair, but that will come back.
Medically serious side effects -
Ovaries -Teenage women who have bipolar illness or epilepsy and take this drug are more likely to have cysts on their ovaries. They also may be more likely to have a disorder called Polycystic Ovary Syndrome. This means you have irregular periods (or none), extra hair, and sometimes obesity and acne. The male hormones are elevated. This disorder can make people infertile.
So does Epival cause Polycystic Ovary Sydrome?
One group of researchers found that 80% of women under age 20 who were put on this drug developed Polycystic Ovary Syndrome (1).However it is not exactly clear. This is because women who have Polycystic Ovary Sydrome and are not on Valproate can show features of bipolar disorder, too. Nevertheless, there is a good chance that Epival can cause Polycystic Ovary Syndrome, especially in women under age 20. (2).
What can you do about this possible Risk?
Right now, monitoring is the best approach. Some people recommend that any teenage girl who is going to be put on Epival should have a pelvic ultrasound done first along with some blood tests for male hormones. These tests should be repeated in a year. If there is no change, you can be quite positive that the child is not developing Polycystic Ovary Syndrome. (2).
Weight gain - In women under age 20 with epilepsy, 82% gained a substantial amount of weight. The same question comes up as before. Is it the epilepsy or the drug? In this case, it is more clear. Probably it is the drug.
Liver - this drug can damage the liver in rare cases (2 out of 100,000) so the liver tests need to be checked regularly, like every four months or so.
Blood- this drug can rarely reduce blood counts (2 out of 10,000) (10)
Pregnancy - It can cause serious birth defects if it is taken during pregnancy.
The drug comes in 250mg and 500 mg pills called Epival. You can start taking nearly the full dose right away. The dose in milligrams is usually ten times the weight in pounds each day. Blood levels are checked at regular intervals.
None of the mood stabilizers for bipolar disorder are as safe as we would like. When weighing the risks of the medication you need to balance the risk of the untreated condition versus the risk of the medication. In severe bipolar illness, the risk of the disorder far exceeds the risk of the medication. In very mild cases, it is best to try to get by without these drugs. In between cases require a lot of thought and conversation between families and doctors.
Lacey is 15. She has had mania with a depressed mood for almost a year. She was hospitalized and started on Lithium. It did nothing. Blood tests and a pelvic ultrasound were done and found to be normal. She was started on Epival. She weighs 110 lbs. She was started on 500 mg twice a day. Within a week she was 100% better. There did not appear to be any side effects. The blood level was checked after a week and was found to be in the therapeutic range. Lacey took the drug for a year. At that point she had gained 15 lbs. She was not fat, but thought she could do all right without it. Her pediatric psychiatrist agreed. She stopped the drug, and has not relapsed. She never did lose that weight.
This is a drug which is used all the time for seizures in children and adults. It has been used for temper problems and bipolar disorder in adults. There is less data to support its use than Divalproex (Epival) in adults. In children there are only a few reports on its use in bipolar children. (8)
Some of the common side effects are sedation, slurred speech, being off balance and rashes. It can upset a child's stomach and produce rashes.
It rarely can effect the liver or the salts in the blood. It also can rarely produce a very serious skin condition. As a result blood tests are done to check the liver and the salts on a regular basis and the drug is always stopped if there is any sign of a rash.
On the positive side, it does not seem to be associated with as much weight gain, it doesn't cause acne, and it comes in a chewable tablet.
While these drugs can be effective, one of the most common reasons for medical treatment not working in teenagers with bipolar disorder is that they don’t take the medication. Sometimes this has to do with side effects but in my experience it usually is because they do not believe they need it or do not believe they will ever get ill again. These drugs cause side effects and require blood tests. In a recent study, about half of the teenagers who had mania either would not take the medications at all or stopped them on their own. (11) It is not clear yet from the data whether or not the new drugs will result in better compliance, but I certainly have found them to be better tolerated.
Second Generation (also called atypical) Antipsychotics
These drugs were first used for schizophrenia, and that is how they got this name. They are now commonly used for many conditions where people are not psychotic. On adults they work for mania and depression.
This drug has been studied the most for pediatric patients. It has been found to be effective in pediatric bipolar disorder using about 1-2 mg a day. About 85% responded. (13) Risperidone is called Risperidal and comes in a variety of sizes; .25mg, .5 mg, 1mg, 2mg and liquid. It also helps Tourettes and Conduct Disorder and psychosis. Usually this is given two or three times a day. This drug usually shows an effect within hours of a dose.
This drug was recently approved for mania in adults. It has been studied less in children. However the early reports are positive. (14) The usual dose is about 5-15 mg a day. It comes in 2.5 mg, 5mg and 10 mg. It is also called Zyprexa. It is more expensive than Risperidone and in adults is associated with more weight gain. This can be given once a day.
This drug is a little different than the above ones as it seems to cause very little problems with things like tremor and stiffness. The dosage range is 200-800 mg a day. It has been found to cause a moderate amount of weight gain in children. There are only a few articles on its use in children and adolescents, but these have been quite positive. (15) It comes in a 25mg and 100 mg size and has to be given twice a day. It is called Seroquel.
Side Effects of Second GenerationAntipsychotics
Weight Gain. This is the biggest problem with these drugs in children. Not all kids gain weight, but a fair number can get 10-30lbs or more. Obviously this is something we watch very carefully. Overall Zyprexa causes the most weight gain, then Seroquel, followed by Risperidal. This is sometimes very hard to manage. It is key to weigh children every visit and start with a diet at the first sign of weight gain. There should also be a weight above which alternative drugs are tried. There is some data to support the use of a drug called Topamax for this. This is described below.(click here)
Stiffness, restlessness, and tremor - these occasionally happen with these drugs, too, but to a much less extent than with the others. This is called drug induced Parkinson’s. This is reversible if the dosage is reduced or the drug is stopped. It can be treated with drugs for Parkinson’s if necessary. Overall it is most common with Risperidal, then Zyprexa, and least common with Seroquel.
Elevated Cholesterol and Triglycerides It was thought that only those people who were gaining weight got this, but now it is clear that it can happen with children who do not gain a lot of weight. Zyprexa is the most likely to cause this, followed by Seroquel, and least likely is Risperidal.
Diabetes This can come out of the blue or be worse on these medications. Zyprexa is the most likely to cause this, followed by Seroquel, and least likely is Risperidal.
Tardive Dyskinesia This is a movement disorder where people can have chewing movements of the mouth, grimacing, head movements, trunk movements and hand movements. The movements are not jerky but smooth and rhythmic. Risperidal is the most likely to cause this, and the other two are very unlikely to cause it.
How do you tell if a child has this movement disorder?
There is a physical exam tool called the AIMS or Abnormal Involuntary Movement Scale which is used to check for dyskinesias. The scale describes all the different kinds of movements in the dyskinesia family. (click here to go to a copy of this and the instructions.) These were very common with the older antipsychotics, but are less common with the newer drugs. In adults, with the older drugs, these movements can last for months or even years after the drug is stopped. In children taking these newer antipsychotics, the movements almost always disappear within a few months of stopping the drug. Certain things make tardive dyskinesia more likely.
Low IQ - children with mental retardation are at higher risk
Dyskinetic movements to start with - If you have some of these movements before you even take the drug, you are more likely to get Tardive Dyskinesia.
Taking an antipsychotic for a longer time
Taking Risperidal instead of Olanzepine. In a recent study, no children on Olanzepine ever got Tardive Dyskinesia even though they were on the drug longer than the children on Risperidal.
How common are dyskinesias in children who are not on any drugs?
About 4% of children have these movements.
How common is Tardive Dyskinesia with atypical antipsychotics in children?
It is impossible to know for sure. A recent study with many children who had mild or borderline mental retardation showed that after a year on atypical antipsychotics at a dose of about 3-4 mg a day, 4 out of 46 (8.5%) had Tardive Dyskinesia. (17)
How do you manage this problem?
Before I ever put a child on an atypical antipsychotic drug, I do an AIMS examination. I recheck it every three months. If I see evidence of new dyskinesias, I discuss with the family what to do. There are a number of things to consider:
How bad is the Tardive Dyskinesia? If it is very mild, it probably isn't worth doing much about, however if it is worsening, it is a bigger concern.
How severe is the disorder we are treating? A slight chewing movement is better than being totally out of control with bipolar disorder.
Sexual Side effects
Risperdal (risperidone) can increase a hormone in the body called Prolactin. This hormone is normally involved in breast feeding. As a result it can lead to breast enlargement (called gynecomastia), a milk like substance coming out of the breasts (called galactorhea), and irregular periods. While only girls get galactorrhea and mentstral problems, boys can get gynecomastia.
This sounds horrible! How often does this happen?
In a recent study of 504 children ages 5-15 who took Risperdal for a year, 22 boys and 3 girls developed gynecomastia, or about 5%. (21)
That sounds like a lot!
The problem is that gynecomastia is quite common in adolescent boys normally. It occurs in about 1/3 of boys. (22)
Does it go away?
In this study, the gynecomastia disappeared while the child was on risperidal in 8 of the 25 who had this side effect. Usually, when the medication is stopped, the gynecomastia disappears, but there have been rare cases where it doesn’t. (21)
Galactorrhea sounds bad, too
Only one of the 85 girls in this study developed galactorrhea. This always resolves when the drug is stopped. The menstral irregularities also usually return to normal if the drug is stopped. (21)
What about the other drugs?
Other drugs in the category (Zyprexa, Seroquel) almost never cause this side effect.
How can you tell who is going to get this?
You can’t. Even measuring the prolactin level doesn’t predict who will get this. (23)
The bottom line…………..
Sexual side effects are pretty rare, not medically serious, but psychologically devastating to children if they occur and have not been told about it before hand.
Malignant Syndrome This is a
rare reaction to antipsychotic medication where people are very ill and have a
fever, stiffness, and they are not thinking clear. It can be very serious and
has even caused deaths. But it is very rare. With the older drugs, it was found
in about 3-4 cases out of 1000. With the newer drugs it is harder to say. Risperidone is the most prescribed antipsychotic for
children and adults in
Psychiatric symptoms These drugs can make a child very anxious, depressed, and even can make them more violent. This is all reversible upon stopping the medication. No drug is more or less likely to do this. My experience is that it affects younger children more often.
As mentioned above, this drug has been found be effective for bipolar depression. This is based on adults with bipolar I. It does not work for mania. (19)
It has been used in teenagers but it can not be given to children younger than 16 because they frequently can get a very severe skin rash which can kill them. This can still rarely happen in people over 16. The rash is much less likely if the dose is slowly increased. The usual dose is 25-200 mg a day. It is started at 12.5 mg a day. Besides the rash, it is pretty well tolerated. It can make people manic. As a result, it usually is given with another mood stabilizer like Lithium.
This drug started off as a medicine for epilepsy. It is quite safe. The amazing thing is that it caused weight loss, not weight gain. So people tried to use it for weight gain from atypical antipsychotics, and sometimes it works. The biggest side effect is that sometimes it can make people feel dopey. It also can cause numbness and tingling. The dose is 25-200 mg a day. I find that older kids have less side effects from this. In children, there is very little data on this.
When is it used?
As an add on for weight gain from medications.
This drug comes
from Tegretol. It has less side effects and is often
more beneficial. You only have to check blood tests monthly. There are no blood
levels of it to check here in
This drug has been used a lot, but careful testing has shown it to be ineffective for violence, bipolar disorder, and aggression.
Since there have been no controlled studies of bipolar depression in children, what should be done?
Make sure you give psychotherapy a good try.
Although there is little data to support this approach, if a child is not severely ill with depression, this is a much safer approach than Lithium, Lamictal, or antidepressants.
Make sure you give other non-medical treatments for depression a good try.
Click here to go to that section of the Depression handout.
Give Lithium and or the Second Generation Antipsychotics a good try, as these have been found to work in adults. If the child is over 16, I would tryLamictal.
If the above medications plus psychotherapy don’t work, I would try an antidepressant. In my practice, I can not think of more than a few children under age 16 with bipolar depression who I have had to consider adding antidepressants because they have failed Medications with or without psychotherapy.
For more information on Depression medications click here.
Unfortunately, very few people will have a good response to one drug alone. How does this happen?
Lithium plus Risperidal - Jonathan is 13 years old. He was irritable from about age 8 on but his parents would tell you that his disease didn't begin until windows starting breaking when he was age 15. This was because he would get so made that he would throw things (like knick-knacks) so hard that he broke out a few windows. Then he starting fighting in school. Hardly a sign of bipolar illness. However, that is just how his uncle was when he first got ill in his teens with bipolar illness. The uncle died of suicide at age 22. By the time I saw him he was on the verge of requiring hospitalization. I wanted to put him on something that worked fast. He started taking Risperidal and he was amazingly better in 24 hours. This worked, but his appetite was uncontrollable. He was gaining a pound every 5 days. So I started him on Lithium, as that doesn’t cause as much weight gain. It worked great, and we were able to cut down the Risperidal to .5 mg a day. When we reduced it below that, he got very agitated again. So now he is on both drugs.
Lithium plus Epival - Julie is 15. She was very depressed and became manic after receiving an antidepressant. Two days into a second antidepressant she was starting to get the same way, so her mom stopped the drug. We started her on Lithium and she did well for a year. Even with a blood level of 1.1, she started to get mood swings and worse depression. Julie was already overweight. We added Epival and she did much better. After a year we will try to cut out the Epival. A recent study showed that this combination can be effective for both depression and mania (22).
Lithium plus Zyprexa plus Lamictal - Tanya is 18. She was in the hospital for 2 months before her mania could be controlled. It took both the Lithium and Zyprexa to do this. Three months later she became severely depressed. Lamictal was added and she was kept on the other drugs for fear she might get manic.
If you have been keeping track, many of the drugs cause weight gain. When they are used in combination, this can be an even bigger problem. After a year of treatment, adults gain an average of 8.1 lbs on Risperidal. But when they took Risperidal plus either Lithium or Epival, the gained an average of 16 lbs. With Zyprexa, the situation is even worse. Those who took Zyprexa alone gained an average of 10.1 lbs. Those who took Zyprexa with Lithium or Epival gained and average of 27 lbs after one year! (20)
But what if there is nothing else that works?
Here is the Plan-
Start nutrition counseling and diet changes immediately, not just after there has been a big weight gain.
Involve a dietician.
Weigh people on every visit.
Try Topamax, which can cause weight loss when added to psychiatric medications. See above for details (click here to go to that spot)
In most children and adolescents, bipolar disorder doesn’t just appear out of the blue one day. In other words, there are early signs that they are getting ill. Often there are some signs of mania, some signs of depression, but they don’t last that long and aren't that severe. There is usually a lot of irritability.
If there is a biological parent who has bipolar illness, it is quite likely that this child is also developing the illness.
But is it better to wait until they show the full picture or start medical treatment before they show all the signs and symptoms of the disease?
There is unfortunately no specific treatment of this type for bipolar illness. There are a few types of counseling used in bipolar children.
If you have bipolar illness, it is a terrifying experience. Children need to learn all about it from Doctors, nurses, families, and other people with bipolar illness.
This includes things like hobbies, music, sports, exercise, cutting down on video, church groups, camping, fishing and the like. All of these can be very effective in dealing with this illness.
This involves teaching families and children about the impact of noncompliance, how to tell if you are relapsing, and what to do to avoid getting sick. In this category are things like avoiding substance abuse and not getting sleep deprived.
If a child has been ill with bipolar illness, it has, by definition, been rough on some of the other people in the family. Other sibs have often been ignored. Some members are scared of being alone with the person. Others might think it is someone's fault (or theirs). Often pediatric psychiatrists and other professionals need to meet with families to work this out.
If a person has or had bipolar illness, they need help getting back into the community. The same concerns that family members have are often found in the community and school. Pediatric Psychiatrists and other professionals often need to work with teachers, community groups, and churches to help victims of bipolar illness get back into the mainstream of life.
Whether children abuse drugs or not makes a bigger difference than if they take medications or not. It is just as important to keep teens with bipolar disorder street drug free as it is to make sure they take their medication. In the long term, staying free of street drugs is one of the biggest factors in preventing relapses. (11)
What we are all hoping and praying for:
A good response to medication.
While there are some children who respond well to the first drug, they are the exception, not the rule. It is not unusual to have to try two or three drugs to finally get the depression, manic symptoms, and cycling under control.
Minimal side effects of the medication.
As noted above, none of these are benign medications. I have yet to see a child who was not bothered at least somewhat by some side effects. Almost 50% of the children I see are going to have to have their medication changed, eliminated, or reduced because of side effects. Often I end up under treating bipolar illness because the side effects are as bad as the disorder itself. This is where the non-medical treatments come in. Anything you can do to reduce the need for medication is worth trying.
Only one medication.
By adulthood, the average bipolar patient is on three or four drugs. With childhood onset bipolar illness, the average is 2-3 drugs in my practice.
The medication keeps working
How many children with bipolar illness are seen every 4-6 months just to make sure everything is going well and never relapse in between? In my practice, less than a quarter. Between side effects and losing effectiveness, it is not uncommon to have to do something every few months.
The child keeps taking the medication
Once children reach adolescence, at least 70 % go through a phase of not taking their medication for one reason or another.
The medication is stopped and the child continues to do well and never gets ill again.
It does happen, and is worth praying for, but it is important to not feel like a failure if this doesn’t happen to your child.
Remember those initial examples? Here is how the four steps might play out in those cases.
When Justin arrived with the RCMP, he was absolutely wild. Even though he was only 11, it took five adults to bring him in. After quickly obtaining consent from his parents, Justin was given 4 mg of Ativan by needle, as he would not stop screaming long enough to take a pill. A half hour later, he was a lot calmer, but still very wound up. The Ativan was repeated a few times that day and he slept 12 hours that night. He was started on Lithium as it had worked very well in his uncle who has bipolar illness. Over the next two weeks, he returned to his old self, but was a little depressed. That was the easy part. Justin's mom and dad blamed Justin for getting ill. His older sister was afraid of him. The school wanted a full time aide to be with him at all times in case he "lost it". Well, between the pediatric psychiatrist, a psychologist, and the uncle, they finally got it all straightened out. Justin returned to most of his previous activities and also started scouts. Six months later he is well, but kids still whisper about him.
After those two weeks of hypomania resolved, Sarah was mostly alone. Her friends thought she was too weird. She stopped playing basketball, did worse in school, and started smoking. She started writing very dark poems and finally decided she wanted to kill herself and told her ex-boyfriend, who told her parents, who brought her to the hospital. The physician was busy and didn't ask about hypomania. Sarah was put on Zoloft 50mg a day for a week. At that point she was to see the pediatric psychiatrist. After a week she was certainly different, but not exactly better. She couldn't sit still, she was very restless, and had kicked her dog hard enough to break the dg's ribs. After a few days in the hospital taking nothing, she returned to her old depressed self. Sarah didn't care if this was a drug side effect or drug induced hypomania. She was not going to take any more medications. So, the parents worked hard at getting Sarah involved in some new activities. If she didn't go do these things (writing class, drama club, basketball) she would have to go see the pediatric psychiatrist (who she hated) or go to the hospital (which she hated even more). So, with an Aunt acting as counselor, she eventually did pull out of her depression, except in the winter, when she still was a little more irritable than usual.
After Alex was on probation for two months, his parents figured he must be back into drugs or else getting ill again. A few urine tests (for street drugs) later, it was obvious it was a relapse into hypomania. He became more violent at school and at home. Between the pediatric psychiatrist, the parents, probation officer, and the school, they decided to admit him once more to the hospital. He was in the hospital almost two months by the time he was tried on Epival, lithium, and finally stabilized on a new mood stabilizer, Lamictal. Unfortunately, his mother had reached her limit of bipolar illness. She would not let him return home, even if he was better. The school basically said the same thing. So Alex ended up in at his Uncle's about 100 Km from home. Luckily, his Uncle was not fishing, because Alex needed a lot of attention to keep his mind off all of what had happened. They spent the winter setting snares, ice fishing, hunting, and playing pool. By spring, after a lot of encouragement from everyone, the mom agreed to take him back for a few months.
Pediatric bipolar illness is rarely mild. It frequently causes major turmoil in the life of the child, community, and family. What is worse, it often hits children who already have a neuropsychiatric problem. Sometimes the medical treatments work great, but often they do not. Even when they do, there can be a lot of problems that remain with families, compliance, and getting people back into their old lives. Since this is a disorder characterized by numerous episodes, the relapses can absolutely destroy patients, families, and helping professionals.
If you have a child with bipolar illness, you need to take care of yourself. Most likely, this is going to be a long term severe stress on you and your family. See the hints on managing this in the conduct disorder pamphlet. click here to go there
Perhaps the hardest thing about Bipolar illness is that it is treatable. You can make a difference. As the examples show, there is usually no medical "magic bullet". Dealing with an illness like this takes a lot out of everyone, but there is no alternative. Giving up on a child with bipolar illness, regardless if you are a parent, patient, child, sibling, doctor or other helping professional, is a recipe for suicide.