AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Bipolar disorder is a mood disorder in which feelings, thoughts, behaviors, and perceptions are altered in the context of episodes of mania and depression. Previously known as manic depression, bipolar disorder was once thought to occur rarely in youth. However, approximately 20% of adults with bipolar disorder had symptoms beginning in adolescence. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (DSM-IV TR), does not distinguish adult onset from childhood or adolescent onset of symptoms of bipolar disorder. Indeed, the diagnostic criterion for bipolar disorder is the same regardless of the patient's age at the onset of symptoms. Despite clinically important differences in the way mood disorders, particularly behavioral differences, may manifest in a child or an adolescent, no diagnostic accommodation has been made on the basis of age.

The DSM-IV TR uses universal symptoms to define the diagnostic criteria for mood episodes, including major depressive and manic episodes. One true manic episode, with or without psychotic features, is the necessary and sufficient criterion for type I bipolar disorder. A depressive episode is insufficient for this diagnosis, even in the presence of a strong family history of bipolar disorder. Type II bipolar disorder is diagnosed on the basis of at least 1 hypomanic episode. Therefore, bipolar disorders are viewed as having a spectrum of symptoms that range from mild hypomania to the most extreme mania, which may include life-threatening behaviors, dysphoria, and psychotic features.

Hallmark symptoms of mania include an abnormal, often expansive, and elevated mood lasting for at least 1 week. Mania may also include a decreased need for sleep, racing thoughts or a sense that thoughts are out of control, rapid and often pressured speech, increased goal-directed activities or projects, hypersexuality, reckless behaviors and risk taking, and delusions of grandeur. Delusions associated with mania frequently center around an expansive sense of self that goes well beyond narcissism, eg, believing oneself to have special (eg, supernatural) powers or to be the chosen leader of the world or universe.

For some, the elevated and elated mood may transform into a state of dysphoria during which agitated and irritable behaviors may develop. Cognitive impairment in mania may manifest as episodes of confusion with a flight of ideas and disorganization of thought. In addition, increased risk taking may involve physical, emotional, or financial endangerment. Moreover, poor insight into one's disorder or behaviors and poor judgment accompany mania. Therefore, the person's financial accounts or important relationships may be in such disarray as to lead to adverse outcomes, including loss of important friends and family support or connections, serious financial setbacks, job losses, legal problems, and homelessness.

According to the DSM-IV TR, criteria for a manic episode are as follows:

• The individual has a distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week (or any duration if hospitalization is necessary).
• During the period of mood disturbance, 3 or more of the following symptoms persisted (4 if the mood is only irritable) and have been present to a significant degree:
  • Inflated self-esteem to levels of grandiosity
  • Decreased need for sleep
  • More talkative than usual, often with pressured speech with a sense of a need to keep talking
  • Flight of ideas or subjective feeling that thoughts are racing
  • Distractibility
  • Increased goal-directed activity or psychomotor agitation
  • Excessive involvement in pleasurable activity that has a high potential for painful consequences (eg, hypersexuality, excessive spending, impetuous traveling)
• The symptoms do not meet the criteria for a mixed episode.
• The mood disturbance is sufficiently severe to cause marked social impairment in occupational functioning, social activities, or relationships with others. Hospitalization may be necessary to prevent harm to self or others or if psychotic features are present.
• The symptoms are not due to the direct physiologic effects of a substance or a general medical condition.

Hypomania is somewhat similar to mania, but it is less severe and less debilitating than true mania. As such, hypomania is defined as an elevated mood during which (1) no hospitalization has ever been necessary, and (2) no state of delusional or other psychotic thinking ever coincided with the elevated mood. Hypomanic and manic states must cause impairment of normal functioning to be considered pathologic states.

An abnormal behavioral episode may be designated a bipolar disorder after the frequency and type of abnormal mood are considered. Therefore, an episode may be reported as a bipolar disorder with a single manic episode, with recurrent manic episodes, or by the mood state of the most recent episode (eg, depressed, mixed, hypomanic, manic). Descriptors such as with psychosis or without psychosis are used to further clarify and reflect the severity of the state of the disorder.

Mood disturbances in children and adolescents are often more difficult to recognize and diagnose than those in adults. Some of the difficulty arises in recognizing atypical symptoms, including irritability, tantrums, physical aggression, and other behavioral problems, such as expressions of mood disruptions. Perhaps this difficulty is best demonstrated in symptom recognition and proper, but controversial, diagnosis of bipolar disorder in youths. The classic symptoms of mania, including racing thoughts, pressured speech, hypersexuality, and grandiosity, more often match the presentation of bipolar disorder in late adolescence. In childhood- or prepubertal-onset bipolar disorder, such a classic cluster of symptoms is uncommon. Nonetheless, as early as 1921, Kraepelin reported that 38% of his 900 patients who had manic episodes had symptom onset when younger than 20 years, and 0.4% had onset of symptoms when younger than 10 years.

Despite Kraepelin's early observation and description of childhood-onset and adolescent-onset bipolar disorders, the controversy about diagnosing bipolar disorder in young persons persists. This is partially driven by the requirement of discrete episodes of disturbed mood to diagnose bipolar disorder. Unlike what is noted in adults, well-defined and discrete episodes of abnormal mood are often missing in children and adolescents with this disorder. In particular, according to the DSM-IV TR criteria, at least 1 discrete episode of mania or hypomania is necessary to diagnose bipolar disorder type I or II.

Clinicians often use the diagnosis of bipolar disorder not otherwise specified (NOS) in children and adolescents with a chronically mixed or vacillating mood state. Children with this diagnosis may have clinically significant impairment though they do not meeting specific criteria for bipolar disorder type I or II.

Because no distinction is made for symptoms of adult-, adolescent-, or childhood-onset bipolar disorder, clinicians are challenged to distinguish abnormal mood symptoms in adolescents and children from normal developmental behaviors, oppositional or defiant behaviors, inattention or hyperactivity, and conduct problems. Childhood-onset bipolar disorder frequently has an insidious onset with affective storms often associated with the presentation of mental illness.

Frequency

United States

The overall prevalence of bipolar I disorder in adolescents is approximately 1%, whereas the prevalence in children is 0.2-0.4%.

Age

• Most patients with bipolar disorder present in early adulthood at the age of 20-30 years. The second most common age group at presentation is 15-19 years.
• In contrast to Kraepelin's report that 38% of his patients had an onset when they were younger than 20 years, more recent estimates are that 20-30% of adults with bipolar I disorder had symptom onset when younger than 20 years. In addition, approximately 20% of youths in whom a major depressive disorder previously diagnosed develop symptoms consistent with a manic state at a later age. Therefore, an adolescent or child who initially presents with depression may have a hidden bipolar disorder that becomes obvious later in life.
• Patients with a childhood onset of bipolar symptoms may have a course of illness that is more severe, chronic, and refractory than that of patients with a later onset of symptoms of bipolar disorder. In addition, an early onset of bipolar symptoms seems to be associated with increased risk of mixed mood states (combined symptoms of depression and mania simultaneously) and rapid cycling (>3 episodes of mania in 1 y).

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

No laboratory study can be used to confirm the diagnosis of bipolar disorder. Therefore, gathering the history of present and past disturbances of mood, behavior, and thought is critical to properly diagnose a psychiatric condition such as bipolar disorder. Unlike other areas of medicine in which the clinician often relies on laboratory or imaging studies to identify or characterize a disorder, mental health professionals rely almost exclusively on descriptive symptom clusters to diagnose mental disorders. As a consequence, the history is an essential part of the patient examination.

• The appropriate first step in evaluating a person for a psychiatric disorder is to ensure that no other medical condition is causing the mood or thought disturbance. Therefore, evaluation of the patient is best started by obtaining their oral history of current and past medical and behavioral symptoms and treatments. To further clarify the problem, gathering additional information from family and friends always is urged for a person experiencing an altered mood or behavioral state.
• After interviewing the patient, perform a physical examination. Gather information from family, friends, and perhaps other physicians to whom the patient is known. The problem might be classified as being primarily caused by a physical health problem or by a mental health problem.
• • While obtaining the history, the physician must explore the possibilities that substance abuse or dependence, trauma to the brain in the present or past, and/or seizure disorders may be contributing to or causing the current symptoms of illness.
  • CNS insults, such as encephalopathy or medication-induced mood changes (ie, steroid-induced mania), must also be considered. Delirium is one of the most important medical conditions to exclude early in persons presenting with altered mental states or acute disturbances of mood and conduct.
  • Perhaps more relevant to youth is the evaluation of substance abuse patterns because acute drug intoxication states may mimic bipolar disorder.
• If the physical examination does not reveal a medical condition contributing to the patient's mental state, a thorough mental health evaluation is appropriate. Through observation and interviewing, mental health professionals may learn of mood, behavioral, cognitive, or judgment and reasoning abnormalities.
• The mental status examination (MSE) is the essential component of a mental health evaluation. This examination goes beyond the mini-mental status examination (eg, Folstein Mini-Mental State Examination to screen for dementia) often used in emergency departments. Rather, the MSE is used to assess the general appearance and demeanor, speech, movement, and interpersonal relatedness of the patient with the examiner and others.
• • Mood and cognitive abilities (eg, orientation to circumstance; attentiveness; immediate-, short-, and long-term modes of memory) are assessed in the MSE.
  • Some of the most important components of the MSE are those addressing issues of safety of individuals and members of a community. Therefore, suicidal and homicidal issues are explored.
  • Likewise, screens for the more subtle forms of psychosis, such as paranoid or delusional states, in addition to screens for overt psychosis, such as observing the patient responding to unseen others or other non–reality-based internal stimuli, are explored.
  • Finally, insight into the patient's mental and physical states, the current circumstances of medical or mental healthcare, and the patient's ability to use age-appropriate judgments are assessed and integrated into the evaluation of the global mental state of the patient at that moment.
• Because bipolar disorder may cause a transient but marked impairment of judgment, insight, and recall, several sources of information are crucial to understand a particular patient. Therefore, family members, friends, teachers, caregivers, or other physicians or mental healthcare workers may be interviewed to clarify the full clinical picture.
• Nonetheless, the patient's subjective experience is essential in the evaluation and treatment processes, and the establishment of a therapeutic alliance and trust early in the assessment is vital to obtaining an accurate and useful history from the patient.
• Knowledge of the family's psychiatric history is another essential part of the patient's history because bipolar disorder has genetic transmission and familial patterns. A genogram may be developed to further describe a particular patient's risk bipolar disorder based on familial and genetic attributes in the family system.

Physical

• Physical examination must include general neurologic examination, including examination of the cranial nerves, muscular bulk, and tone and deep tendon reflexes.
• Cardiovascular, pulmonary, and abdominal examinations are also essential because abnormal pulmonary function or poor vascular perfusion of the brain may cause abnormal mood, behavior, or cognition.
• Both physical and laboratory thyroid examination should be performed because of the potential mood alteration in hypothyroid and hyperthyroid states.
• If these examinations do not reveal a medical condition contributory to the current mental state, a mental health evaluation should be performed (see History).

Causes

• Genetic and familial factors have profound influence in the propagation of bipolar disorder.
  • Chang and colleagues (2000) reported that children who have at least 1 biologic parent with bipolar I or bipolar II disorder have increased psychopathology. The specific finding was that 28% of the children examined had attention deficit/hyperactivity disorder (ADHD). This rate is far above the prevalence of 3-5% in the general population of school-aged children. Also, 15% of the children had a bipolar disorder or cyclothymia. Approximately 90% of children who have bipolar disorders had comorbid ADHD. Moreover, both bipolar disorder and ADHD were more likely to be diagnosed in boys than in girls.
  • Early age of onset of bipolar disorder is predictive of a higher rate of mood disorder among first-degree relatives of the proband (Faraone, 1997). Also, adolescents who have onset of true mania with childhood-associated psychotic symptoms, such as aggression, mood shifts, or attention difficulties, have a greater genetic risk (family loading) for bipolar I disorder than adolescents with more adult-related psychotic symptoms, such as grandiosity. Other unique features of youths with early-onset bipolar disorder include (1) poor or ineffective response to lithium therapy (administered as Eskalith) and (2) an associated increased risk of alcohol-related disorders in the family members of the probands.
  • Twin studies of bipolar disorder showed a 14% concordance rate in dizygotic twins and a 65% concordance rate (range, 33-90%) in monozygotic twins. The risk for the offspring of a couple in which 1 parent has bipolar disorder was estimated to be 30-35%. For an offspring of a couple in which both parents have bipolar disorder, the risk was approximately 70-75%.
  • Faraone et al further delineated the differences among children with mania, adolescents with childhood-onset mania, and adolescents with adolescence-onset mania.
    • Socioeconomic status (SES) was statistically lower in families of children with mania and adolescents with childhood-onset mania than in others.
    • Increased energy was twice as common in childhood mania than in other forms, euphoria was most common in adolescents with childhood-onset mania, and irritability was least common in adolescents with adolescent-onset mania.
    • On statistical analysis, adolescents with adolescent-onset mania abused psychoactive drugs and had more impaired parent-child relationships than individuals in the other 2 groups with mania.
    • ADHD was more common in children and adolescents with childhood-onset mania than in patients with adolescent-onset mania. This finding led the authors to theorize that ADHD may be a marker for juvenile-onset mania.
  • Data from this and other studies (Strober, 1998) suggest that a subtype of bipolar disorder may exist. This subtype may have a high familial transmission rate, and affected individuals present with childhood-onset of mania symptoms suggestive of ADHD.
  • Faraone et al propose that early-onset mania may be the same as the comorbid state of ADHD and bipolar disorder, which has a high rate of familial transmission. The question exists regarding whether youths who are later given the diagnosis of bipolar disorder may have a prodromal phase in early life that appears to be ADHD or another behavioral disturbance or whether many simply have bipolar disorder and comorbid ADHD.
• Cognitive and neurodevelopmental factors also seem to be involved in the development of bipolar disorder.
  • A case-cohort study of adolescents with affective disorders revealed that neurodevelopmental delays are overrepresented in early-onset bipolar disorders (Sigurdsson, 1999). These delays occur in language, social, and motor development approximately 10-18 years before affective symptoms appear.
  • Adolescents who had early developmental antecedents were at high risk of developing psychotic symptoms. In addition, intelligence quotient (IQ) scores were significantly lower in patients with early-onset bipolar disorder (mean full scale IQ, 88.8) than in patients with unipolar depression (mean full scale IQ, 105.8).
  • Finally, a statistically significant difference in the mean verbal IQ and mean performance IQ was found only in patients with bipolar disorder. The reason for this discrepancy is unclear but should be the subject of further investigation.
  • Overall, patients with severe bipolar disorder had a mean IQ lower than that of patients with mild-to-moderate forms of the disorder.
• Finally, environmental factors also contribute to the development of bipolar disorder. These may be behavioral, educational, family-related, toxic, or substance abuse induced.
• Diagnoses of mental health problems increase the risk of suicide in adolescents compared with their healthy peers.
  • Adolescent patients in whom bipolar disorder is diagnosed are at higher risk of suicide than adolescents with other behavioral illnesses. Family conflict and substance abuse exponentially increase this risk.
  • Another risk factor for suicide in youths is legal problems. One study showed that 24% of adolescents who attempted suicide had faced legal charges or consequences in the past 12 months.
• Incarcerated youths also have an inordinately high number of mental illnesses. Some are facing legal consequences as a direct result of behaviors that arise from uncontrolled or untreated mental disorders. The manic state of bipolar disorder can be particularly problematic for adolescents because the disinhibited risk-taking behaviors driven by the disorder can easily lead to legal problems, such as public disorderly conduct, theft, drug seeking or use, and an agitated and irritable mood that results in verbal and physical altercations.

Biologic and biochemical factors

• Sleep disturbances often aid in defining abnormal mood states of bipolar disorder in either the manic or depressed state.
• • A profoundly decreased need for sleep in the absence of a sense of fatigue is a strong indicator of a manic state.
  • An uncomfortable reduction of sleep is a pattern of an atypical depression episode in which more sleep is wanted but cannot be achieved. Conversely, a typical depression episode may be indicated by hypersomnolence, an excessive but irresistible need for sleep.
  • The biology that drives these anomalies of sleep in mood disturbances is not fully appreciated. Some suggest that neurochemical and neurobiologic shifts cause these episodic sleep disturbances in conjunction with other shifts that occur in the evolution of manic or depressed states.
• Bipolar disorder and other mood disorders are increasingly understood in the context of neurochemical imbalances in the brain.
• • Although the circuits of the brain that modulate mood, cognition, and behavior are not well defined, the database of neuroimaging studies that facilitate increased appreciation of possible modulating pathways that connect several brain regions to work in unison to regulate thoughts, feelings, and behaviors is constantly growing.
  • An association of neurotransmitters acts upon various brain regions and circuits to modify and regulate brain activity. Table 1 reflects the putative roles of some CNS neurotransmitters in brain circuits.

    Table 1. Neurotransmitters of the CNS

    Neurotransmitter	Activity Modified
    Serotonin	Mood (happy, sad, euthymic)
    Dopamine	Pleasure (hedonia, anhedonia)
    Norepinephrine	Alertness, energy level (lethargy, frenzy, vigilance)
    Acetylcholine	Memory and cognition
    GABA	Inhibition of CNS neurons
    Glutamate	Excitation of CNS neurons

  • One proposal suggests that several neurotransmitters acting in unison but with dynamic balance act as modulators of mood states. In particular, serotonin, dopamine, and norepinephrine appear to modify mood, cognition, and sense of pleasure or displeasure.
  • Pharmacotherapy for the regulation of bipolar mood swings is thought to be based on the use of medications that facilitate the regulation of these and perhaps other neurochemicals to restore a normal mood and cognition state.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

On presentation to healthcare services, youths with bipolar disorder exhibit behaviors that mimic and overlap those of other diagnoses. The overlap of bipolar symptoms with symptoms of ADHD and conduct disorder is notable. As in patients with bipolar disorder, activity is increased, and self-esteem may be inflated in the early stages of ADHD and conduct disorder. Societal and educational responses to the behaviors of ADHD and conduct disorder may ultimately reduce self-esteem in these patients compared with those with bipolar disorder. Table 2 lists many other features of bipolar disorder compared with ADHD and conduct disorder. These may help in comparing and contrasting the clinical features of these 3 important disorders that affect young individuals.

Table 2. Differential Diagnosis Considerations

Behavior	Bipolar Disorder	ADHD	Conduct Disorder
Self-esteem	Inflated	Inflated and/or deflated	Inflated and/or deflated
Pleasure	Euphoric in mania Dysphoric in mixed or depressed state	Often dysphoric or euthymic	Pleasure in violating societal norms, especially if not caught
Attention	Distractible	Distractible	Normal to vigilant
Hyperactivity	Goal directed	Unproductive	Goal directed
Sleep	Episodic disturbances such as decreased need in mania	Chronic poor sleep; often late bedtimes	Not known to be disrupted except with substance abuse
Speech	Pressured or rapid in mania; slow in depression	Often rapid; may be pressured	May be normal rate
Impulsivity	Externally driven; reactionary	Internally driven	May have predatory or reactionary acts
Social	Often good	Often poor	Often poor
Academic	Often good	Often poor	Often poor
Psychomotor activity	Agitated in mania or mixed states; retarded in depressed states	Chronically agitated	Easily agitated

Additional consideration must be given to the possibility of the existence of schizophrenia or schizoaffective disorder, posttraumatic stress disorder (PTSD), substance abuse, or anxiety states (eg, generalized anxiety disorder, social anxiety disorder) because any of these disorders may transiently mimic bipolar disorder. Rarely is dementia an issue in youths, but this may need to be excluded in some patients (particularly after head trauma).

Comorbidity

Biederman et al (Biederman and Milberger, 1996) noted that the combination of conduct disorder and major depression in adolescence could be predictive of bipolar disorder in a 4-year follow-up assessment of those patients. An estimated 10-15% of adolescents who present with recurrent episodes of major depression later are given the diagnosis of bipolar disorder. Also, children with ADHD who later develop bipolar disorder have increased rates of other psychiatric conditions, including opposition defiant disorder (ODD). Overall, the combined symptoms of severe ADHD, unstable affect, and aggression may be predictive of bipolar disorder later in life for children in whom ADHD is already diagnosed.

Biederman et al reported that an important predictor of bipolar disorder in youth was disruptive behavior disorder (DBD). The data specifically suggested that the combination of ADHD with ODD, versus ADHD alone, was correlated with a future onset of bipolar symptoms at rates of 7% and 5%, respectively. When ADHD was present with ODD that progressed to conduct disorder, the occurrence of bipolar disorder dramatically increased to 44%. That is, approximately 55% of adolescents who have a diagnosis of comorbid ADHD, ODD, and conduct disorder do not have an onset of bipolar symptoms. Nonetheless, a potential complication to note in youths who have comorbid ADHD and ODD is the development of bipolar features, including depression and psychosis. Also, the combination of ADHD and ODD increases the risk of the patient's becoming involved in legal activities and incarceration. Therefore, bipolar symptoms already exist or may develop in some incarcerated youths.

Kovacs and Polack (1995) performed a prospective study of 26 prepubertal youths in whom bipolar disorder and conduct disorder manifested at the age of 8-13 years. In their 12-year follow-up evaluation, the lifetime comorbidity for these 2 disorders was 69%. Additional review of the pattern of psychiatric pathology revealed that, of those in whom both disorders began when they were younger than 13 years, conduct disorder was diagnosed first in 42%, whereas bipolar disorder was diagnosed first in 27%.

Because clinicians are often concerned that conduct disorder increases the risk of antisocial personality disorder, careful screening and monitoring for the comorbid conditions of bipolar disorder and conduct disorder may be necessary in youth who present with either of these disorders. Such screening may help to identify and treat these youths so they may avoid incarceration and perhaps erroneous labeling as antisocial adults rather than individuals with coexisting bipolar disorder and conduct disorder.

Incarcerated youths have a disproportionately high prevalence of bipolar disorders compared with youths in the general population. Steiner (2000) estimated that 2% of incarcerated juveniles have bipolar I disorder, whereas 4% have bipolar II disorder.

Another commonly observed comorbid diagnosis in youths with bipolar disorder is ADHD. Among prepubertal youths presenting with bipolar symptoms, nearly 90% have a diagnosis of ADHD; among adolescents, about 30% have ADHD (Geller, 1997).

In summary, sustained symptoms of conduct and impulse control problems may be warning signs of a prepubertal onset of bipolar disorder.

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Initial tests for substance and alcohol abuse are usually necessary to exclude drugs and alcohol as causative agents for behavior.
• No specific blood or other laboratory tests aid the mental health professional in diagnosing bipolar disorder.
• • Of interest, serum cortisol levels may be elevated, but this is not of diagnostic or clinical value.
  • Thyroid studies may help assure the clinician that an altered mood is not secondary to a thyroid disorder.
  • The clinician may order tests of serum blood chemistries, such as basic metabolic panels and liver function tests, to help assess renal and hepatic health before starting or continuing certain medications to help regulate or ameliorate bipolar symptoms.
  • Mania and depression both may involve states of malnutrition secondary to the psychiatrically diminished awareness of or ability to maintain one's health and well-being. Thus, a metabolic panel along with, in extreme cases, levels of thiamine, albumin, and prealbumin may help determine the extent of self-neglect and compromised nutritional state.
  • After pharmacotherapy is implemented, periodic laboratory tests may be required to monitor drug levels and to ensure that no adverse response to the medication is harming renal or hepatic function.

Imaging Studies

• Neuroimaging modalities are currently not helpful in diagnosing bipolar disorder. Rather, the clinical presentation of symptom clusters, as defined in the DSM-IV TR, plus family and genetic histories guide the mental health clinician in diagnosing psychiatric conditions.
• Neuroimaging studies of child and adolescent patients with bipolar disorder are few. MRI studies of children and adolescents with bipolar I disorder have shown enlarged ventricles and an increased number of hyperintensities compared with healthy control subjects. The pathologic and clinical significance of these findings is unknown.
• In MRI studies, Dasari et al (1999) found that the area of the thalamus was substantially decreased in youths with bipolar disorder or schizophrenia compared with healthy control subjects. Studies in adults revealed similar findings. The diagnosis of bipolar disorder or schizophrenia cannot be made on the basis of this volume difference on MRI. Nonetheless, reduced thalamic volume is consistent with clinical symptoms of poor attention, difficulty in filtering simultaneous stimuli, and dysregulation of mood, all of which symptoms found in patients with both of these major mental illnesses. Whether a structural or functional deficit in the thalamus may be causal or contributory to the pathophysiology of these mental disorders remains unknown.

Other Tests

• A baseline ECG may be needed before a psychotropic medication is started because some are known to alter QT intervals or other features of the cardiac rhythm.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

The treatment and management of bipolar disorder are complicated. Hence, most children and adolescents with this diagnosis require referral to a psychiatrist specializing in their age group. In general, a team approach is used in the clinical setting because several factors need to be addressed, including medication, family issues, social and school functioning, and, when present, substance abuse. In general, the treatment of bipolar disorder may be thought of as a 4-phase process: (1) evaluation and diagnosis of presenting symptoms, (2) acute care and crisis stabilization for psychosis or suicidal or homicidal ideas or acts, (3) movement toward full recovery from a depressed or manic state, and (4) attainment and maintenance of euthymia.

The treatment of adolescent or juvenile patients with bipolar disorder is modeled after treatments provided to adults because no good controlled studies of bipolar treatment modalities in this age group are available to enable evidence-based medical care. Nonetheless, bipolar disorders in adolescents and children often present to clinicians at times of family or youth despair or family crises surrounding their behaviors. In such critical times, inpatient care often is indicated to assess the patient, diagnose the condition, and ensure the safety of the patient or others. Hospitalization is necessary for most patients in whom psychotic features are present and in almost all patients in whom suicidal or homicidal ideations or plans are present. Inpatient care should always be considered for young persons who have suicidal or homicidal ideation and have access to firearms in their homes or communities and for those who abuse substances, particularly alcohol.

Depressive episodes are not uncommonly the first presentation of bipolar disorders in youths. In these situations, the clinician is wise to recall that approximately 20% of adolescents who have a diagnosis of depression later reveal manic symptoms; thus, antidepressant therapy in a depressed youth should be initiated with a warning to the patient and family of the possibility of later development of mania symptoms. If history of a manic state is known or suggested in a currently depressed patient, then a mood stabilizer must be started first. Once a therapeutic level and response to the mood stabilizer are attained, an antidepressant may be considered as additional treatment needed for the current state of depression.

Inpatient treatment usually requires locked-unit care to assist in safety regulation. Rarely are young persons physically restrained in hospitals, but seclusion rooms remain available in the event of severely agitated states that may culminate in threats or overt expression of physical aggression to self or others.

Mood stabilizers, such as lithium carbonate, sodium divalproex, or carbamazepine, have traditionally been the mainstays of treatment of patients with bipolar disorder. However, atypical antipsychotics are increasingly used in bipolar disorder with or without psychotic symptoms. This class of medications includes risperidone, quetiapine, olanzapine, aripiprazole, ziprasidone, and clozapine. In addition, benzodiazepines may be used to improve sleep and to modulate agitation during hospitalization. After symptoms of psychosis, suicidality, or homicidality are absent or sufficiently diminished to a safe and manageable level, the patient is discharged to outpatient care.

Although electroconvulsive therapy (ECT) is well documented as an effective and safe treatment option in patients with depressive or psychotic states, most clinicians do not consider this a first-line intervention in children or adolescents. ECT is often initially administered on an inpatient basis because it most frequently is used in severe or refractory cases, and these patients are likely to require hospitalization more often. Still, ECT may be started at any point in treatment because each ECT treatment can be performed in a day-treatment setting. Therapy requires at least a 4-hour visit for pre-ECT preparations, delivery of the ECT, and monitoring during recovery from both ECT and anesthesia. All ECT treatments require the presence of an anesthesiologist or anesthetist throughout the administration of therapy.

ECT has been demonstrated to be both safe and therapeutic in adolescents and children. One favorable aspect of ECT is its more rapid onset of therapeutic response versus medications, specifically in days rather than weeks. One drawback to ECT is the associated memory loss surrounding the time just before and after treatments. An ECT treatment episode may involve 3-8 or more sessions, usually at a rate of 1 session every other day or 3 sessions per week. Despite the rapid effect of ECT on mood and psychotic symptoms, medications are still required in the maintenance phase of treatment.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Children and adolescents with bipolar disorder are treated with medications, though none of these medications—with the sole exception of lithium (in patients as young as 12 y)—have received approval from the US Food and Drug Administration (FDA) for this application. Despite the paucity of data, pediatric treatment guidelines have evolved based on empirically derived plans. The Child Psychiatric Workgroup on Bipolar Disorder established guidelines based on the most up-to-date evidence (Kowatch, 2005). In general, these guidelines involve algorithm-based use of mood stabilizers and atypical antipsychotic agents alone or in various combinations.

Use of mood-stabilizing agents in children and adolescents has unique considerations. In general, metabolism is faster in adolescents and children than in adults because of the efficiency of their hepatic functions. Also, adolescents and children have faster renal clearance rates than adults. For example, lithium carbonate has an elimination half-life of 30-36 hours in an elderly patient, 24 hours in an adult, 18 hours in an adolescent, and <18 hours in children. Steady states also are achieved earlier in children than in adolescents and earlier in adolescents than in adults. Therefore, plasma levels may be drawn and assessed earlier in children and adolescents than in adults.

Consequences of the efficient metabolizing and clearance systems of young individuals are as follows: (1) Anticipated peak plasma drug levels may be higher in young patients than in adults, and (2) anticipated plasma trough levels may be lower in young patients than in adults. Therefore, children may require increased dosages of medications (milligrams/kilogram/day) to attain a therapeutic response. Special precautions must be taken when one doses psychiatric medications to treat adolescents and children to achieve therapeutic effect while staying safely below toxic levels.

Although the mood stabilizers have not been established as primary treatment of bipolar disorders in adolescents or children in large-scale controlled studies, they are used clinically in this context. Mood stabilizers include lithium carbonate, valproic acid or sodium divalproex, and carbamazepine. These medications still are considered first-line agents in managing bipolar disorders in pediatric patients because case reports and limited studies have suggested that they have sufficient efficacy and safety to provide symptom relief and control.

Lithium carbonate is effective in approximately 60-70% of adolescents and children with bipolar disorder and remains the first-line therapy in many settings. Approximately 15% of children receiving lithium have enuresis, primarily nocturnal enuresis. In those whose condition does not respond to lithium, sodium divalproex is generally the next agent of choice. As in adults with bipolar disorder, carbamazepine is often considered a third choice, after sodium divalproex and lithium carbonate have been tried at optimal doses for a sufficient length of time. This medication often is tried after an acute or crisis state is stabilized and when adverse effects of sodium divalproex or lithium carbonate are intolerable.

Lamotrigine has been approved for bipolar maintenance therapy in adults, but data in pediatric patients are lacking. Other antiepileptic medications (eg, gabapentin, oxcarbazepine, topiramate) have had mixed results in adults with bipolar disorder in case reports and studies. However, limited data are available regarding the potential usefulness of these medications in pediatric patients with bipolar disorder, though a benefit may theoretically be possible.

Emerging evidence indicates that atypical antipsychotic agents may be used in pediatric patients with bipolar disorder who presents with or without psychosis. Given the antimanic properties demonstrated in adult and limited adolescent studies, olanzapine (Zyprexa), quetiapine (Seroquel), and risperidone (Risperdal) may be considered first-line alternatives to lithium, valproate, or carbamazepine. Pediatric studies with ziprasidone (Geodon) and aripiprazole (Abilify) are limited at this point; this limitation indicates that these agents should be considered second-line alternatives if first-line mood stabilizers or atypical antipsychotic agents are ineffective or if they result in intolerable adverse effects. Clozapine (Clozaril) may be considered only in treatment-refractory cases given its need for frequent hematologic monitoring due to the risk for agranulocytosis.

An important consideration with atypical antipsychotics is the potential for weight gain and metabolic syndrome. The patient's weight should be measured, and a fasting lipid profile and serum glucose level should be evaluated before these agents are started, and these values should be monitored periodically during treatment. Patients and families should be advised of the need to appropriately manage diet and exercise. Limited data indicate that ziprasidone and aripiprazole may have a low potential for these adverse effects and that they may be considered in patients at high risk because of a family or personal history of metabolic abnormalities. Atypical antipsychotics also pose a potential risk for extrapyramidal symptoms and tardive dyskinesia.

Table 3 lists common adverse effects and special concerns for first-line medications.

Table 3. First-Line Medications for Pediatric Bipolar Disorder: Common Adverse Effects and Special Concerns

Medication	Common Adverse Effects	Doses	Special Concerns
Lithium carbonate (Eskalith CR, Lithobid)	GI distress, lethargy or sedation, tremor, enuresis, weight gain, alopecia, cognitive blunting	10-30 mg/kg/d; dose must be adjusted by monitoring serum level and patient response; uptitrate on twice-daily schedule	Hypothyroidism, diabetes insipidus, toxic in dehydration, polyuria, polydipsia, renal disease; drug-drug interactions and sodium intake may alter therapeutic serum levels
Sodium divalproex/valproic acid (Depakote, Depakene)	Sedation, platelet dysfunction, liver disease, alopecia, weight gain	15-30 mg/kg/d; dose must be adjusted by monitoring serum levels; uptitrate on twice- or thrice-daily schedule	Elevated liver enzymes or liver disease, drug-drug interactions, bone marrow suppression
Carbamazepine (Tegretol)	Suppressed WBC, dizziness, drowsiness, rashes, liver toxicity (rare)	10-20 mg/kg/d; dose must be adjusted by monitoring serum blood levels; uptitrate on twice-daily schedule	Drug-drug interactions, bone marrow suppression
Risperidone (Risperdal)	Weight gain, sedation, orthostasis	0.25 mg bid or 0.5 mg at bedtime initially; titrate as tolerated to target dosage of 2-4 mg/d; not to exceed 6 mg/d	Galactorrhea, extrapyramidal symptoms
Quetiapine (Seroquel)	Sedation, orthostasis, weight gain	50 mg bid initially; titrate as tolerated to target dosage of 400-600 mg/d	Decrease dosage with hepatic impairment, may cause neuroleptic malignant syndrome (NMS) or hyperglycemia
Olanzapine (Zyprexa)	Weight gain, dyslipidemia, sedation, or orthostasis	2.5-5 mg at bedtime initially; titrate as tolerated to target dosage of 10-20 mg/d	Metabolic syndrome, extrapyramidal symptoms

Benzodiazepines, such as clonazepam and lorazepam, generally are avoided, but they may be temporarily useful in restoring sleep or in modulating irritability or agitation not caused by psychosis. Because of the slow-on and slow-off action of clonazepam (Klonopin), the risk of abuse is lower with this drug than with fast-acting benzodiazepines such as lorazepam (Ativan) and alprazolam (Xanax). In the outpatient setting, clonazepam may be preferred because of the efficacy and the lowered risks of abuse by the patient or others. Clonazepam can be dosed in the range of 0.01-0.04 mg/kg/d, and it is often administered once per day at bedtime or twice per day. Lorazepam is dosed to 0.04-0.09 mg/kg/d and administered 3 times per day because of its short half-life.

When a patient with bipolar disorder is having a depressive episode, the use of an antidepressant may be considered after a mood stabilizer or atypical antipsychotic agent has been started and after a therapeutic response or level is achieved. Caution must be exercised in starting an antidepressant in a person with bipolar disorder because it may precipitate mania. An antidepressant with a potentially lowered risk of inducing mania is bupropion (Wellbutrin).

Selective serotonin reuptake inhibitors (SSRIs) may also be used. However, because of the risk of mania, doses should be low and titration should be slow. The only SSRI currently FDA approved for the management of unipolar depression in adolescents is fluoxetine (Prozac). However, this agent should be used carefully in patients with bipolar disorder because of its long half-life and because of its potential to exacerbate manic symptoms when not coadministered with an antimanic or mood-stabilizing agent.

All medications used in pediatric bipolar disorder pose a risk of adverse effects or interactions with other medications. These risks should be clearly discussed with patients and families and weighed against the potential benefits. Medication should be started only after informed consent is obtained.

Drug Category: Mood stabilizers

These drugs are indicated for control of manic episodes occurring in bipolar disorder. Mood stabilizers include lithium carbonate, valproic acid or sodium divalproex, and carbamazepine.

Drug Name	Valproic acid (Depacon, Depakene, Depakote)
Description	Proven effectiveness in treating and preventing mania. Classified as mood stabilizer and can be used alone or in combination with lithium. Useful in treating rapid-cycling bipolar disorders and has been used to treat aggressive or behavioral disorders. Combination of valproic acid and valproate has been effective in treating persons in manic phase, with a success rate of 49%.
Adult Dose	Initial: 250 mg PO tid in increments until a serum level of 350-700 mmol/L (50-100 mcg/mL) achieved Maintenance: 750-3000 mg PO qd in divided doses Manic episode: Loading dose of 20 mg/kg/d PO Stat dose: 20 mg/kg PO, with next dose in 12 h; then 10 mg/kg bid Maintenance: 500-3500 mg PO qd to achieve plasma level of 50-125 mcg/mL
Pediatric Dose	15-30 mg/kg/d PO divided bid/tid; must adjust dosage must by monitoring serum levels; uptitrate on bid/tid schedule
Contraindications	Documented hypersensitivity; hepatic disease or dysfunction; hyperammonemic encephalopathy and urea cycle disorders
Interactions	Coadministration with cimetidine, salicylates, felbamate, and erythromycin may increase toxicity; rifampin may significantly reduce valproate levels; in pediatric patients, protein binding and metabolism of valproate decrease with concomitant salicylates; coadministration with carbamazepine may result in variable changes of carbamazepine concentrations with possible loss of seizure control; valproate may increase diazepam and ethosuximide toxicity (monitor closely); valproate may increase phenobarbital and phenytoin levels, and either may decrease valproate levels; valproate may displace warfarin from protein-binding sites (monitor coagulation); may increase zidovudine levels in HIV-seropositive patients
Pregnancy	D - Unsafe in pregnancy
Precautions	Thrombocytopenia and abnormal coagulation parameters have occurred; risk of thrombocytopenia substantially increases at total trough valproate plasma concentrations >110 mcg/mL in female patients and >135 mcg/mL in male patients; determine platelet counts and bleeding time before therapy, periodically, and before surgery; reduce dose or discontinue if hemorrhage, bruising, or hemostasis or coagulation disorder occurs; hyperammonemia may occur, resulting in hepatotoxicity; closely monitor patients for malaise, weakness, facial edema, anorexia, jaundice, and vomiting; may cause drowsiness

Drug Name	Carbamazepine (Tegretol)
Description	Anticonvulsant action may involve depressing activity in nucleus ventralis anterior of thalamus, reducing polysynaptic responses and blocking posttetanic potentiation. Reduces sustained, high-frequency, repetitive neural firing. Potent enzyme inducer that can induce own metabolism. Because of potentially serious blood dyscrasias, weigh benefit and risk before therapy. Therapeutic plasma levels 4-12 mcg/mL for analgesic and antiseizure response. Serum levels peak in 4-5 h. Serum half-life 12-17 h with repeated doses. Metabolized in liver to active metabolite (epoxide derivative) with half-life of 5-8 h. Metabolites excreted in feces and urine. Effective in cases that do not respond to lithium therapy. Has been effective in treating rapid-cycling bipolar disorder.
Adult Dose	Initial: 200 mg PO bid in divided doses with 100-mg increments 2 times/wk; if adverse effects occur, decrease dose by 200 mg Dose range: 300-1600 mg PO qd Serum-level range: 17-50 mmol/L (4-12 mcg/mL) Manic episode: 200-1800 mg PO qd
Pediatric Dose	10-20 mg/kg/d PO divided bid/tid; must adjust dosage by monitoring serum blood levels; uptitrate on bid schedule
Contraindications	Documented hypersensitivity; history of bone marrow depression; administration of MAOIs in last 14 d
Interactions	Serum levels may substantially increase within 30 d of danazol coadministration (avoid whenever possible); do not administer concurrently with MAOIs; cimetidine may increase toxicity, especially if taken in first 4 wk of therapy; may decrease primidone and phenobarbital levels (coadministration may increase carbamazepine levels)
Pregnancy	D - Unsafe in pregnancy
Precautions	Not for relief of minor aches and pains; caution with increased intraocular pressure; obtain CBCs and serum-iron baseline before treatment, during first 2 mo, and yearly or every other year thereafter; can cause drowsiness, dizziness, and blurred vision; caution while driving or performing other tasks requiring alertness

Drug Name	Risperidone (Risperdal)
Description	Binds dopamine D2-receptor with 20 times lower affinity than for 5-HT2-receptor. Indicated for short-term (3-wk) treatment of acute mania associated with bipolar disorder. May use alone or combined with lithium or valproate.
Adult Dose	2-3 mg PO qd up to 3 wk; may increase by 1 mg/d at 24-h intervals, not to exceed 6 mg/d
Pediatric Dose	Data limited; 0.25 mg PO bid or 0.5 mg qhs initially; titrate as tolerated to target dosage of 2-4 mg/d; not to exceed 6 mg/d
Contraindications	Documented hypersensitivity
Interactions	Coadministration with carbamazepine may decrease effects; may inhibit effects of levodopa; clozapine may increase levels; PO solution not compatible with cola or tea
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	May cause extrapyramidal reactions, hypotension, tachycardia, and arrhythmias; hyperglycemia (some cases extreme) may occur, resulting in ketoacidosis, hyperosmolar coma, or death; do not split or chew PO disintegrating tablets

Drug Name	Quetiapine (Seroquel)
Description	May act by antagonizing dopamine and serotonin effects. Newer antipsychotic used for long-term management. Improvements over earlier antipsychotics include fewer anticholinergic effects and less dystonia, parkinsonism, and tardive dyskinesia.
Adult Dose	Initial: 25 mg PO bid/tid; increase by 25-50 mg bid/tid on day 2 or 3 to achieve range 300-400 mg divided bid/tid by day 4; adjust as needed at intervals of >2 d with adjustments of 25-50 mg bid Maintenance: 150-750 mg/d PO; not to exceed 800 mg/d
Pediatric Dose	Data limited; 50 mg PO bid initially; titrate as tolerated to target dosage of 400-600 mg/d
Contraindications	Documented hypersensitivity
Interactions	May antagonize levodopa and dopamine agonists; phenytoin, thioridazine, and other liver enzyme inducers may reduce levels; cytochrome P450 (CYP) 3A inhibitors (eg, ketoconazole, fluconazole, erythromycin) increase serum concentration
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	May induce orthostatic hypotension associated with dizziness, tachycardia, and syncope; has been associated with NMS and tardive dyskinesia; hyperglycemia (some cases extreme) may occur, resulting in ketoacidosis, hyperosmolar coma, or death; caution in hepatic impairment (decrease dose)

Drug Name	Olanzapine (Zyprexa)
Description	Mechanism of action for acute manic episodes associated with bipolar I disorder unknown. Available as tab, PO disintegrating tab (Zyprexa, Zydis), and IM dosage forms.
Adult Dose	10-15 mg PO qd; adjust by 5 mg/d at intervals >24 h; not to exceed 20 mg/d Agitation associated with bipolar mania: 10 mg IM once; may repeat after 2 h; not to exceed 30 mg/24 h Geriatric or debilitated individuals: 2.5-5 mg IM/dose
Pediatric Dose	Data limited; 2.5-5 mg PO qhs initially; titrate as tolerated to target dosage of 10-20 mg/d
Contraindications	Documented hypersensitivity
Interactions	Fluvoxamine may increase effects; antihypertensives may increase risk of hypotension and orthostatic hypotension; levodopa, pergolide, bromocriptine, charcoal, carbamazepine, omeprazole, rifampin, and cigarette smoking may decrease effects
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in narrow-angle glaucoma, cardiovascular disease, cerebrovascular disease, prostatic hypertrophy, seizure disorders, hypovolemia, and dehydration; hyperglycemia (some cases extreme) may occur, resulting in ketoacidosis, hyperosmolar coma, or death; administration of >1 IM injection associated with substantial orthostatic hypotension (33%), maintain patient in recumbent position and monitor blood pressure before repeating IM doses

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• The goals of inpatient or outpatient treatment are to control and minimize symptoms of bipolar disorder, lengthen the periods of normal mood states or euthymia, minimize the number of needed hospitalizations, eliminate or minimize medication adverse effects to a tolerable level, and optimize the quality of life for the patient. Quality-of-life issues for a young person include meaningful relationships with family, peers, mentors, coaches, and teachers; optimal academic performance; and optimal occupational performance as it pertains to endeavors such as music, art, dance, athletics, or other personally rewarding areas from which the adolescent derives a sense of competency, mastery, and pleasure.
• Although current treatments are empirically derived, most clinicians in outpatient settings provide and recommend both individual and family therapy in addition to medication monitoring and management.
• • Cognitive and behavioral methods are used in adolescents, and behavioral methods usually are used in the preadolescent population. This difference is based on the idea that preteens are not cognitively or verbally mature enough to respond to cognitive restructuring methods.
  • Family therapy is encouraged because adjusting to having a child who has bipolar disorder is a family matter that involves parents, the identified child, and siblings.
  • The goals of individual therapy and family therapy should be individualized. Nonetheless, global goals of reduction of family stress, improvement of family communications, and addressing unresolved feelings of fear, hurt, or loss as a result of having a mental disorder affect a loved family member are common themes.
  • In the family and individual sessions, medication issues and compliance also should be addressed so that optimal care can be attained in the outpatient setting.
  • Finally, the patient and family need psychoeducation about bipolar disorder and its management.
• In mental healthcare centers and in private practices, most patients and their families receive care from many professionals.
• • Psychiatrists, psychologists, behavioral and developmental pediatricians, social workers, and many other therapists are involved in treating the patient, monitoring the response to and tolerance of medications, and providing psychotherapy to the family and the patient.
  • In the ideal situation, these professionals work together in a team approach so optimal care can be attained in the medical, educational, family, and social realms.

Prognosis

• In general, the onset of bipolar disorder in childhood and adolescence has revealed a stronger family history for bipolar disorder than later onset; therefore, individuals are at increased genetic and familial risk from the beginning of life.
• • An emerging body of evidence indicates that optimal treatment for the genetic or familial form of bipolar disorder may differ from other treatment modalities of other bipolar conditions.
  • Adverse outcomes of an early onset of bipolar disorder are as follows: (1) The course is generally more severe than that of late-onset disorder, and (2) the course of illness is more refractory to treatment than when the onset starts in adulthood.
• As with so many psychiatric and medical disorders in children and adolescents, increased stress in home, school, and social settings may precipitate or exaggerate early mood disturbances of bipolar disorder. As the patient ages, the tendency for stress to contribute to a mood episode declines, and mood disruptions may occur spontaneously, even with medication and treatment compliance. This trend seems to be found in adults and not in children or adolescents; it is thought to be the result of kindling.
• In the general population, suicide remains one of the top 10 causes of death in adolescents and young adults. It is the fourth most common cause of death in persons aged 10-15 years and the third most common cause of death in persons aged 15-25 years.
• • All persons with bipolar disorder have an increased risk of suicide.
  • The exact increase of the risk in youths is unknown; however, in young adults with bipolar disorder, suicide has a higher incidence in males within the first few years of the diagnosis. Current suicide rates in patients with bipolar disorder are 10-15%.
  • In adults, treatment with lithium reduces the suicide rate; similar studies in adolescents and children do not exist, but lithium has been demonstrated to reduce substance use in adolescents with bipolar disorder.
• Episodic mood events should be anticipated throughout the life cycle after bipolar disorder is diagnosed. The frequency and severity of each episode are not readily predictable, but trends have emerged. In the presence of medication and treatment compliance, relapses may occur, and hospitalization may be required. In the absence of compliance, the course of the illness can be more severe than it would be otherwise.
• One potentially reassuring aspect of bipolar disorder is that patients may potentially have a full and normal life during the periods between mood swings. Therefore, many persons with bipolar disorder may continue their college education and careers with success, and they may foster and nuture strong relationships.

Patient Education

• Psychoeducation of parents and patients is an important aspect of treating an adolescent or child in whom bipolar disorder is diagnosed.
• • The young person must be given the relevant facts in an age-appropriate and developmentally appropriate manner.
  • The diagnosis, benefits of treatment, and detriment of treatment noncompliance should be made clear and understandable.
  • Inpatient and outpatient psychiatrists, psychologists, social workers, and other therapists involved in the care of the youth and the family should be able to aid the patient and family in the understanding and management of bipolar disorder in a loved one.
• Families and patients can learn about adolescent or childhood bipolar disorders at the American Academy of Child and Adolescent Psychiatry Web site in the section titled Resources for Families. This provides a user-friendly fact and information sheet to families about bipolar disorder and its treatment in the pediatric population.
• The Child & Adolescent Bipolar Foundation (CABF) provides important information and resources for families and clinicians.
• Another resource is the Depressive and Manic-Depressive Association, a support group for patients and families of patients who have bipolar disorder. This group is mostly for adults, and parents are far more likely than adolescents or children to benefit from this group.
• For excellent patient education resources, visit eMedicine's Depression Center. Also, see eMedicine's patient education articles, Depression and Bipolar Disorder.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Although bipolar disorder has a low prevalence in childhood and adolescence, the diagnosis may be made in children as young as 5 years whose presentation meets the DSM-IV TR criteria.
• The confidence of this diagnosis in early life may be increased if 1 or both parents also have bipolar disorder.
• In general, a protracted and severe course of illness is associated with an early age of onset of bipolar disorder.
• Treatment with mood stabilizers is a vital part of maintaining optimal functioning in these youths.
• Also, the assessment of comorbid conditions is necessary because comorbid conditions such as substance abuse or ADHD often may be present.

Special Concerns

• Personal caregivers and healthcare providers should not have false expectation that current mood may predict the safety of the patient or others in the future
• Other sources of information include web sites such as the American Psychological Association, National Alliance on Mental Illness, and Depression and Bipolar Support Alliance.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• AACAP Official Action. Practice parameters for the assessment and treatment of children and adolescents with bipolar disorder. J Am Acad Child Adolesc Psychiatry. Jan 1997;36(1):138-57. [Medline].
• APA: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC:. American Psychiatric Association;2000.
• Biederman J, Faraone S, Milberger S, et al. A prospective 4-year follow-up study of attention-deficit hyperactivity and related disorders. Arch Gen Psychiatry. May 1996;53(5):437-46. [Medline].
• Biederman J, Faraone S, Mick E, et al. Attention-deficit hyperactivity disorder and juvenile mania: an overlooked comorbidity?. J Am Acad Child Adolesc Psychiatry. Aug 1996;35(8):997-1008. [Medline].
• Chang KD, Steiner H, Ketter TA. Psychiatric phenomenology of child and adolescent bipolar offspring. J Am Acad Child Adolesc Psychiatry. Apr 2000;39(4):453-60. [Medline].
• Dasari M, Friedman L, Jesberger J, et al. A magnetic resonance imaging study of thalamic area in adolescent patients with either schizophrenia or bipolar disorder as compared to healthy controls. Psychiatry Res. Oct 11 1999;91(3):155-62. [Medline].
• Faraone SV, Biederman J, Wozniak J, et al. Is comorbidity with ADHD a marker for juvenile-onset mania?. J Am Acad Child Adolesc Psychiatry. Aug 1997;36(8):1046-55. [Medline].
• Geller B, Luby J. Child and adolescent bipolar disorder: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry. Sep 1997;36(9):1168-76. [Medline].
• Kovacs M, Pollock M. Bipolar disorder and comorbid conduct disorder in childhood and adolescence. J Am Acad Child Adolesc Psychiatry. Jun 1995;34(6):715-23. [Medline].
• Kowatch RA, Bucci JP. Mood stabilizers and anticonvulsants. Pediatr Clin North Am. Oct 1998;45(5):1173-86, ix-x. [Medline].
• Kowatch RA, Fristad M, Birmaher B, et al. Treatment guidelines for children and adolescents with bipolar disorder. J Am Acad Child Adolesc Psychiatry. Mar 2005;44(3):213-35. [Medline].
• Sigurdsson E, Fombonne E, Sayal K, Checkley S. Neurodevelopmental antecedents of early-onset bipolar affective disorder. Br J Psychiatry. Feb 1999;174:121-7. [Medline].
• Steiner H. Evaluation and management of violent behavior in bipolar adolescents. Symposium 19D. Presented at: The 153rd Annual Meeting of the American Psychiatric Association; May 14, 2000. Chicago, IL.
• Strober M, DeAntonio M, Schmidt-Lackner S, et al. Early childhood attention deficit hyperactivity disorder predicts poorer response to acute lithium therapy in adolescent mania. J Affect Disord. Nov 1998;51(2):145-51. [Medline].
• Tondo L, Baldessarini RJ, Hennen J, et al. Lithium treatment and risk of suicidal behavior in bipolar disorder patients. J Clin Psychiatry. Aug 1998;59(8):405-14. [Medline].

Article Last Updated: Oct 5, 2006