Children and adolescents

Evidence from guidelines

Overview

Only CANMAT and the NICE give any advice in relation to how children and adolescents should manage their bipolar disorder.

CANMAT details that the peak onset of the disorder occurs between the ages of 15 and 19 years.

Both guidelines agree that lithium is effective in adolescents. The CANMAT guideline provides evidence that lithium is effective in combination as well. NICE details that only lithium is licensed for people aged 12 to 18, unless there is no other alternative.

The guidelines differ in recommendations in relation to divalproex, or valproate, as well. CANMAT argues that divalproex has been proved to be effective in RCTs. NICE advises that young girls avoid taking valproate, although lithium and valproate can be prescribed for adolescents during mania.

NICE guideline1

The only drug with current UK marketing authorisation for bipolar disorder in patients younger than 18 years is lithium, which is licensed for those aged 12 and over. However, in 2000 the Royal College of Paediatrics and Child Health stated that unlicensed medicines may be prescribed for children and adolescents where there are no suitable alternatives and where the use is justified by a responsible body of professional opinion.

Acute mania and depression in children and adolescents

Acute mania

Follow the recommendations for treating acute mania in adults, except that drugs should be started at lower doses, and at initial presentation:

  • check height and weight (and monitor regularly afterwards).
  • measure prolactin levels.
  • if considering an antipsychotic, take into account the risk of increased prolactin levels with risperidone and weight gain with olanzapine.

If response to an antipsychotic is inadequate, consider adding lithium or valproate – but normally avoid valproate in girls and young women.

Depression

Monitor weekly if symptoms are mild and do not need immediate treatment, and offer additional support at home and school.

If treatment is needed, it should normally be by specialist clinicians. Treat as for adults, but consider a structured psychological therapy in addition to prophylactic medication.

If this does not produce a response after 4 weeks, consider:

  • adding fluoxetine starting at 10mg per day, and increasing to 20mg per day if needed.
  • using a different SSRI (sertraline or citalopram) if there is no response to fluoxetine.

If there is still no response, ask for advice from a specialist in affective disorders.

For developmentally advanced adolescents, follow the recommendations on managing depression in adults.

Long-term treatment of children and adolescents

Long-term management should normally be by specialist clinicians (based in at least Tier 3 services).

Treat as for adults, but:

  • consider as first line an atypical antipsychotic that is associated with less weight gain and does not increase prolactin levels.
  • consider as second line lithium for female patients and valproate or lithium for male patients.
  • give parents and carers support to help the patient maintain a regular lifestyle.
  • advise the school or college (with permission of the patient and parents or carers) on managing the patient’s bipolar disorder.

CANMAT guideline2

The child psychiatric workgroup on bipolar disorder has recently published guidelines for treatment of children and adolescents with this condition and the reader is referred to this document for more details on this topic.3

Presentation and diagnosis

Approximately 53-66% of bipolar patients experience their first episode during childhood and adolescence, with a peak age of onset between 15 and 19 years of age.

Acute and maintenance treatment of paediatric bipolar disorder

The early course of bipolar disorder in adolescents is often chronic and refractory to treatment, while the long-term prognosis appears similar to that of adults. Although available data are limited, and have methodological issues, the results of both RCTs and open clinical trials suggest that adolescent-onset bipolar disorder will likely respond to the same agents as adult-onset bipolar disorder. Like adult bipolar disorder, childhood-onset bipolar disorder has a chronic course with a high rate of recurrence and evidence suggests that prophylactic therapy is needed.

Lithium

A placebo-controlled RCT in adolescents with bipolar disorders and comorbid substance abuse showed that acute treatment with lithium was effective in both disorders (level 2). Open trials have also suggested that lithium is effective for actue treatment of children and adolescents with manic or mixed episodes (level 3). Lithium was effective in combination with other agents in a retrospective study (level 4).

Divalproex

In prospective, open trials, divalproex was effective for the treatment of children and adolescents with bipolar disorder, with response rates numerically, but not statistically, superior to lithium and carbamazepine (level 3). Long-term treatment with divalproex has been associated with improved outcomes in the treatment of children and adolescents with bipolar disorder (level 4).

Atypical antipsychotics

In an RCT, the combination of quetiapine and divalproex was significantly more effective than divalproex alone in the treatment of acute mania in adolescents with bipolar disorder.

Antidepressants

In general, antidepressant monotherapy is not recommended for the treatment of bipolar disorder. In addition, recent meta-analyses and Food and Drug Administration (FDA) position papers demonstrate an excess risk of suicidality with SSRIs in children and adolescents with depression.

ECT

Data on the use of ECT in adolescents and children come mainly from case studies (level 3). While there are concerns regarding possible adverse effects on the maturing nervous system, several follow-up studies have not found evidence of long-term cognitive impairment in adolescents treated with ECT. The American Academy of Child Adolescent Psychiatry states that ECT may be an effective treatment for adolescents with severe mood disorders and other Axis I psychiatric disorders. They recommended that ECT be considered when there is a lack of response to two or more trials of pharmacotherapy or when the symptoms precludes waiting for a response to pharmacological treatment.

Psychoeducation

Preliminary data suggest benefits from adjunctive group psychoeducation for families of children with mood disorders and child-and-family-focused CBT. 

References

  1. National Institute for Clinical Excellence. The management of bipolar disorder in adults, children and adolescents, in primary and secondary care. National Institute for Clinical Excellence. 2006; Jul
  2. Yatham LN et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines for the management of patients with bipolar disorder: consensus and controversies. Bipolar Disorders. 2005; 7 (3): 5-69.
  3. Huxley N, Parikh S, Baldessarini R. Effectiveness of psychosocial treatments in bipolar disorder: state of the evidence (Structured abstract). Harvard Review of Psychiatry. 2000; 3