Below is a list of the major mood stabilizers. Of all of these, Lithium, Depakote, and Tegretol are the three most commonly used.

• Lithium – Approved for children 12 years and older.
• Depakote -Approved for children 2 years and older for seizures.
• Tegretol – Approved for all ages for seizures.
• Gabapentin – Approved for young people 18 and older. Approved only for epilepsy.
• Lamictal – Approved for young people 18 and older. Approved for seizures in children.
• Topamax – Approved for young people 18 and older and approved for seizures.
• Trilpetal – Approved for children 4 and older and approved for seizures.

LITHIUM

The most well-known, well-studied, and longest used drug for BD is Lithium. Despite favorable publicity, the misconception still exists that Lithium is dangerous. The fear springs from the well-publicized stories of the rare Lithium toxicity reaction. I have prescribed Lithium to many hundreds of patients, young and old, and have only witnessed this reaction once. People can and do take Lithium for years with only positive results.

Lithium can be harmful to the thyroid and to the kidneys over the long term. It is essential that kidney and thyroid function tests be done regularly when taking this drug. Before starting Lithium, your child should have a complete blood count, an ECG, and thyroid and kidney tests.

TEGRETOL

Tegretol (Carbamazine) is an antiepileptic drug used commonly for BD in adults and young people. It is not approved for use in BD and is given off-label. It is approved for use in epilepsy for children as well as adults. Despite this off label use, it has been reported as quite successful in some of the few trials reported. The dosage recommended for young people is up to 300 mgs a day.

Before prescribing Tegretol a complete history and physical examination is necessary. There should be a complete examination of the skin as well as a complete blood count and other blood tests to be sure of the level of liver function.

DEPAKOTE

Depakote, as it is most well-known, is another anti-epileptic medication used as a mood stabilizer. Like with other antiepileptic medication this is used off-label in young people. But it is widely used and considered almost as good as Lithium for BD. It is specifically used quite a bit in teenagers with BD with good results. It is sometimes used as a first line monotherapy like Lithium or in combination with other drugs.

Before starting this drug a complete medical history and physical exam is necessary. There should also be a complete blood count, clotting tests, tests of kidney function, urine analysis, and a pregnancy test for girls. Caution should be taken and full disclosure about PCOS (polycystic ovaries) and pregnancy issues should be made.

DISCLAIMER

Information contained in this blog is intended for educational purposes only. It is not intended as medical or psychiatric advice for individual conditions or treatment and does not substitute for a medical or psychiatric examination. A psychiatrist must make a determination about any treatment or prescription. Dr. Paul does not assume any responsibility or risk for the use of any information contained within this blog.

The treatment of BD in children is similar to that of adult BD. First, we treat whatever the episode that is being experienced – acute phase treatment – and when things get better we focus on preventing future episodes – maintenance phase treatment. Most of the medications for both phases are the same. One must also keep in mind that BD children often have comorbid (additional) diagnoses which might need treatment, as well.

Acute Phase Treatment

The acute phase of treatment of BD means medicating a child who is either manic or depressed (but depressed with a history of mania or hypomania) or one who has TDD.

The initial acute phase treatment for mania without psychotic features (hallucinations and delusions), or TDD starts with monotherapy treatment with one drug. The one drug is either a mood stabilizer such as Lithium, Depakote, or Tegretol, or less commonly Gabapentin, Trileptal, or Topamax, or an antipsychotic drug such as Risperdal, Seroquel or Zyprexa, or less commonly Abilify or Geodon. If a child only partially responds than an augmenting agent is often tried in conjunction with the first medication. Usually this consists of adding an antipsychotic to a mood stabilizer or conversely a mood stabilizer to an antipsychotic. Alternatively, if the child does not respond to monotherapy the psychiatrist sometimes skips the augmentation phase and just switches to another of the original choices of monotherapy listed above. Again, there is still an opportunity to add an augmenter. If the child still fails to respond than differing combinations of mood stabilizers and antipsychotics are often tried. On the whole most children do respond to one or more of the more common first line drugs (Lithium, Tegretol, Depakote or Risperdal, Seroquel or Zyprexa).

For BD children with psychotic features, it is common to start with a combination of a mood stabilizer and an antipsychotic drug. If this fails the psychiatrist can switch the combination of these drugs, and then add another antipsychotic medication or add another mood stabilizer. Finally, if all combinations of the common mood stabilizers and antipsychotics are exhausted, less effective mood stabilizers in conjunction with different antipsychotic medications may be prescribed.

Maintenance Phase Treatment

The maintenance phase of drug therapy is aimed at preventing recurrence of episodes of BD. Interestingly the maintenance drugs are the same ones used in the acute phase of treatment. There is little evidence that these drugs work as well in preventing relapses in young people as they do in adults. The maintenance phase usually lasts from one to two years and depends, to a degree, on the level of impairment, the chronicity of the condition, the number of episodes of bipolarity, and the level of stability reached by the youth and the environment in which she lives. While most young patients are able to get off these medications, there will be times that this will prove impossible. Sometimes relapse follows quickly upon stopping the medications. As with some adults, a decision will be made that drug therapy will be maintained indefinitely to help the child or adolescent progress in life, socially, educationally, and vocationally without the risk of further decompensation.

DISCLAIMER

Information contained in this blog is intended for educational purposes only. It is not intended as medical or psychiatric advice for individual conditions or treatment and does not substitute for a medical or psychiatric examination. A psychiatrist must make a determination about any treatment or prescription. Dr. Paul does not assume any responsibility or risk for the use of any information contained within this blog.

Children with Temper Dysregulation Disorder with Dysphoria (TDD) are often misdiagnosed with Bipolar Disorder (BD). Why? Because there is confusion regarding the symptoms. Symptoms that include chronically aggressive, irritable unhappy children with frequent temper tantrums have often been diagnosed as having BD, when actually they should have been diagnosed with TDD.

TDD is a fairly new syndrome that has been known to many of us in the mental health community for years. It is a classification that has been suggested to replace the diagnoses of bipolar children in cases where symptoms include:

1. Having frequent tantrums in response to stress
2. Acting with rage and aggression out of proportion to whatever the cause
3. Having behavior that makes them appear younger than they really are
4. Experiencing these episodes at least several times a week
5. Feeling a lot of irritability, anger, and sadness (dysphoria) in between tantrums
6. Having tantrums that appear in more than one setting (home and school) and that start before a child is ten years old and no earlier than six years old

These symptoms appear quite frequently and they generally have to last a year to officially be called TDD. These children also share other characteristics:

1. They do not have mania.
2. They share a similarity to children with Oppositional Defiant Disorder.
3. They rarely develop BD but are more likely to become depressed as they get older if not treated. I have often seen depressed adults who describe their behaviors as children that sound like TDD.

Medications for BD, TDD, and Accompanying Conditions

Children younger than mid-adolescence rarely present with classically described BD. Therefore, the available treatments are those used for adults, but given to children “off-label”. The medical establishment calls the group of medications “Mood Stabilizers”. Other than Lithium, the most well-known of the group, most of the mood stabilizers were used originally by neurologists to treat epilepsy and are called anti-epileptic medications. These medications are often used in conjunction with antipsychotic medications for children with BD and TDD. Although, formal studies are somewhat lacking, it does seem that these drugs help. For the sake of discussion we will address the BD child as one who either presents as having classic BD (rare) or TDD.

DISCLAIMER

Information contained in this blog is intended for educational purposes only. It is not intended as medical or psychiatric advice for individual conditions or treatment and does not substitute for a medical or psychiatric examination. A psychiatrist must make a determination about any treatment or prescription. Dr. Paul does not assume any responsibility or risk for the use of any information contained within this blog.