Bipolar Disorder in Children and Teens (cont.)

What treatments are available for children and teens with bipolar disorder?

To date, there is no cure for bipolar disorder. However, treatment with medications, psychotherapy (talk therapy), or both may help people get better.

It's important for you to know that children sometimes respond differently to psychiatric medications than adults do.

To treat children and teens with bipolar disorder, doctors often rely on information about treating adults. This is because there haven't been many studies on treating young people with the illness, although several have been started recently.

One large study with adults funded by NIMH is the Systematic Treatment Enhancement Program for Bipolar Disorder. This study found that treating adults with medications and intensive psychotherapy for about nine months helped them get better. These adults got better faster and stayed well longer than adults treated with less intensive psychotherapy for six weeks. Combining medication treatment and psychotherapies may help young people with early-onset bipolar disorder as well. However, it's important for you to know that children sometimes respond differently to psychiatric medications than adults do.

Medications

Before starting medication, the doctor will want to determine your child's physical and mental health. This is called a "baseline" assessment. Your child will need regular follow-up visits to monitor treatment progress and side effects. Most children with bipolar disorder will also need long-term or even lifelong medication treatment. This is often the best way to manage symptoms and prevent relapse, or a return of symptoms.

It's better to limit the number and dose of medications. A good way to remember this is "start low, go slow." Talk to the psychiatrist about using the smallest amount of medication that helps relieve your child's symptoms. To judge a medication's effectiveness, your child may need to take a medication for several weeks or months. The doctor needs this time to decide whether to switch to a different medication. Because children's symptoms are complex, it's not unusual for them to need more than one type of medication.

Keep a daily log of your child's most troublesome symptoms. Doing so can make it easier for you, your child, and the doctor to decide whether a medication is helpful. Also, be sure to tell the psychiatrist about all other prescription drugs, over-the-counter medications, or natural supplements your child is taking. Taking certain medications and supplements together may cause unwanted or dangerous effects.

Some of the types of medications generally used to treat bipolar disorder are listed below. Information on medications can change.

Mood stabilizing medications are usually the first choice to treat bipolar disorder. In general, people with bipolar disorder continue treatment with mood stabilizers for years. Except for lithium, many of these medications are anticonvulsants. Anticonvulsant medications are usually used to treat seizures, but they also help control moods. These medications are commonly used as mood stabilizers in bipolar disorder:

  • Lithium: Sometimes known as Eskalith or Lithobid, lithium was the first mood-stabilizing medication approved by the U.S. Food and Drug Administration (FDA) in the 1970s for treatment of mania. It is often very effective in controlling symptoms of mania and preventing the recurrence of manic and depressive episodes.
  • Valproc acid or vivalproex sodum (Depakote): This substance was approved by the FDA in 1995 for treating mania, and is a popular alternative to lithium for bipolar disorder. It is generally as effective as lithium for treating bipolar disorder. Also see the section in this booklet, "Should young women take valproic acid?"
  • Lamotrigine (Lamictal): More recently, this anticonvulsant received FDA approval for maintenance treatment of bipolar disorder.
  • Other anticonvulsant medications, including gabapentin (Neurontin), topiramate (Topamax), and oxcarbazepine (Trileptal) are sometimes prescribed. No large studies have shown that these medications are more effective than mood stabilizers.

Valproic acid, lamotrigine, and other anticonvulsant medications have an FDA warning. The warning states their use may increase the risk of suicidal thoughts and behaviors. People taking anticonvulsant medications for bipolar or other illnesses should be closely monitored fro new or worsening symptoms of depression, suicidal thoughts or behavior, or any unusual changes in mood or behavior. People taking these medications should not make any changes without talking to their health care professional

Lithium and Thyroid Function

People with bipolar disorder often have thyroid gland problems. Lithium treatment may also cause low thyroid levels in some people. Low thyroid function, called hypothyroidism, has been associated with rapid cycling in some people with bipolar disorder, especially women.

Because too much or too little thyroid hormone can lead to mood and energy changes, it is important to have a doctor check thyroid levels carefully. A person with bipolar disorder may need to take thyroid medication, in addition to medications for bipolar disorder, to keep thyroid levels balanced.

Should young women take valproic acid?

Valproic acid may increase levels of testosterone (a male hormone) in teenage girls and lead to polycystic ovary syndrome (PCOS) in women who begin taking the medication before age 20. PCOS causes a woman's eggs to develop cysts, or fluid-filled sacs that collect in the ovaries instead of being released by monthly periods. This condition can cause obesity, excess body hair, disruptions in the menstrual cycle and other serious symptoms. Most of these symptoms will improve after stopping treatment with valproic acid. Young girls and woman taking valproic acid should be monitored carefully by a doctor.

Atypical antipsychotic medications are sometimes used to treat symptoms of bipolar disorder. Often, these medications are taken with other medications. Atypical antipsychotic medications are called "atypical" to set them apart from earlier medications, which are called "conventional," or "first-generation" anti-psychotics.

Olanzapine (Zyprexa), when given with an antidepressant medication, may help relieve symptoms of severe mania or psychosis.28 Olanzapine is also available in an injectable form, which quickly treats agitation associated with a manic or mixed episode. Olanzapine can be used for maintenance treatment of bipolar disorder as well, even when a person does not have psychotic symptoms. However, some studies show that people taking olanzapine may gain weight and have other side effects that can increase their risk for diabetes and heart disease. These side effects are more likely in people taking olanzapine when compared with people prescribed other atypical antipsychotics.

Aripiprazole (Abilify), like olanzapine, is approved for treatment of a manic or mixed episode. Aripiprazole is also used for maintenance treatment after a severe or sudden episode. As with olanzapine, aripiprazole also can be injected for urgent treatment of symptoms of manic or mixed episodes of bipolar disorder.

Quetiapine (Seroquel) relieves the symptoms of severe and sudden manic episodes. In that way, quetiapine is like almost all antipsychotics. In 2006, it became the first atypical antipsychotic to also receive FDA approval for the treatment of bipolar depressive episodes.

Risperidone (Risperdal) and ziprasidone (Geodon) are other atypical antipsychotics that may also be prescribed for controlling manic or mixed episodes.

Antidepressant medications are sometimes used to treat symptoms of depression in bipolar disorder. People with bipolar disorder who take antidepressants often take a mood stabilizer too. Doctors usually require this because taking only an antidepressant can increase a person's risk of switching to mania or hypomania, or of developing rapid cycling symptoms.29 To prevent this switch, doctors who prescribe antidepressants for treating bipolar disorder also usually require the person to take a mood-stabilizing medication at the same time.

Recently, a large-scale, NIMH-funded study showed that for many people, adding an antidepressant to a mood stabilizer is no more effective in treating the depression than using only a mood stabilizer.

Fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), and bupropion (Wellbutrin) are examples of antidepressants that may be prescribed to treat symptoms of bipolar depression.

Some medications are better at treating one type of bipolar symptoms than another. For example, lamotrigine (Lamictal) seems to be helpful in controlling depressive symptoms of bipolar disorder.

What are the side effects of these medications?

Before your child starts taking a new medication, talk with the doctor or pharmacist about possible risks and benefits of taking that medication.

The doctor or pharmacist can also answer questions about side effects. Over the last decade, treatments have improved, and some medications now have fewer or more tolerable side effects than past treatments. However, everyone responds differently to medications, and in some cases, side effects may not appear until a person has taken a medication for some time.

If your child develops any severe side effects from a medication, talk to the doctor who prescribed it as soon as possible. The doctor may change the dose or prescribe a different medication. Children and teens being treated for bipolar disorder should not stop taking a medication without talking to a doctor first. Suddenly stopping a medication may lead to "rebound," or worsening of bipolar disorder symptoms or other uncomfortable or potentially dangerous withdrawal effects.

The following sections describe some common side effects of the different types of medications used to treat bipolar disorder.

Mood Stabilizers

In some cases, lithium can cause side effects such as:

Lithium may cause other side effects not listed here. Tell the doctor about bothersome or unusual side effects as soon as possible.

If your child is being treated with lithium, it is important for him or her to see the treating doctor regularly. The doctor needs to check the levels of lithium in the child's blood, as well as kidney function and thyroid function.

Each mood stabilizing medication is different and can cause different types of side effects. Some common side effects of lamotrigine and valproic acid include:

These medications may also be linked with rare but serious side effects. Talk with the treating doctor or a pharmacist to make sure you understand signs of serious side effects for the specific medications your child is taking.

  • Atypical Antipsychotics Some people have side effects when they start taking atypical antipsychotics. Most side effects go away after a few days and often can be managed successfully. People who are taking antipsychotics should not drive until they adjust to their new medication. Side effects of many antipsychotics include:
    • Drowsiness
    • Dizziness when changing positions
    • Blurred vision
    • Rapid heartbeat
    • Sensitivity to the sun
    • Skin rashes
    • Menstrual problems for girls
    • Weight gain.

    Atypical antipsychotic medications can cause major weight gain and changes in metabolism. This may increase a person's risk of getting diabetes and high cholesterol. While taking an atypical antipsychotic medication, your child's weight, glucose levels, and lipid levels should be monitored regularly by a doctor.

    In rare cases, long-term use of atypical antipsychotic drugs may lead to a condition called tardive dyskinesia (TD). The condition causes muscle movements that commonly occur around the mouth. A person with TD cannot control these movements. TD can range from mild to severe, and it cannot always be cured. Sometimes people with TD recover partially or fully after they stop taking the drug.

    Antidepressants

    FDA Warning on Antidepressants

    Antidepressants are safe and popular, but some studies have suggested that they may have unintentional effects on some people, especially in adolescents and young adults. The FDA warning says that patients of all ages taking antidepressants should be watched closely, especially during the first few weeks of treatment. Possible side effects to look for are depression that gets worse, suicidal thinking or behavior, or any unusual changes in behavior such as trouble sleeping, agitation, or withdrawal from normal social situations. Families and caregivers should report any changes to the doctor. For the latest information visit the FDA website .

    The antidepressants most commonly prescribed for treating symptoms of bipolar disorder can also cause mild side effects that usually do not last long. These can include:

    1. Headache, which usually goes away within a few days.
    2. Nausea (feeling sick to your stomach), which usually goes away within a few days.
    3. Sleep problems, such as sleeplessness or drowsiness. This may occur during the first few weeks but then goes away. To help lessen these effects, sometimes the medication dose can be reduced, or the time of day it is taken can be changed.
    4. Agitation (feeling jittery)
    5. Sexual problems, which can affect both men and women. These include reduced sex drive and problems having and enjoying sex.
    6. Some antidepressants are more likely to cause certain side effects than other antidepressants. Your doctor or pharmacist can answer questions about these medications. Any unusual reactions or side effects should be reported to a doctor immediately.

    Sexual Activity, Pregnancy, and Teens with Bipolar Disorder

    Many teens make risky choices about sex. The U.S. Centers for Disease Control and Prevention (CDC) recently reported that 26 percent of teenage girls in the United States have at least one of the four most common sexually transmitted diseases. This suggests that many teens are having unprotected sex or taking part in other risky behaviors.

    Bipolar disorder is also linked with impulsive and risky choices. Teenage girls with bipolar disorder who are pregnant or may become pregnant face special challenges because medications for the illness may have harmful effects on a developing fetus or nursing infant. Specifically, lithium and valproic acid should not be used during pregnancy. Also, some medications may reduce the effectiveness of birth control pills.

    Psychotherapy

    In addition to medication, psychotherapy ("talk" therapy) can be an effective treatment for bipolar disorder. Studies in adults show that it can provide support, education, and guidance to people with bipolar disorder and their families. Psychotherapy may also help children keep taking their medications to stay healthy and prevent relapse.

    Children and teens may also benefit from therapies that address problems at school, work, or in the community.

    Some psychotherapy treatments used for bipolar disorder include:

    1. Cognitive behavioral therapy helps young people with bipolar disorder learn to change harmful or negative thought patterns and behaviors.
    2. Family-focused therapy includes a child's family members. It helps enhance family coping strategies, such as recognizing new episodes early and helping their child. This therapy also improves communication and problem-solving.
    3. Interpersonal and social rhythm therapy helps children and teens with bipolar disorder improve their relationships with others and manage their daily routines. Regular daily routines and sleep schedules may help protect against manic episodes.
    4. Psychoeducation teaches young people with bipolar disorder about the illness and its treatment. This treatment helps people recognize signs of relapse so they can seek treatment early, before a full-blown episode occurs. Psychoeducation also may be helpful for family members and caregivers.

    Other types of therapies may be tried as well, or used along with those mentioned above. The number, frequency, and type of psychotherapy sessions should be based on your child's treatment needs.

    A licensed psychologist, social worker, or counselor typically provides these therapies. This professional often works with your child's psychiatrist to monitor care. Some may also be licensed to prescribe medications; check the laws in your state.

    In addition to getting therapy to reduce symptoms of bipolar disorder, children and teens may also benefit from therapies that address problems at school, work, or in the community. Such therapies may target communication skills, problem-solving skills, or skills for school or work. Other programs, such as those provided by social welfare programs or support and advocacy groups, can help as well.

    Some children with bipolar disorder may also have learning disorders or language problems. Your child's school may need to make accommodations that reduce the stresses of a school day and provide proper support or interventions.

    Medically Reviewed by a Doctor on 3/26/2014

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