SPECIAL COMMUNICATION
Treatment Guidelines for Children and Adolescents With Bipolar Disorder

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ABSTRACT

Clinicians who treat children and adolescents with bipolar disorder desperately need current treatment guidelines. These guidelines were developed by expert consensus and a review of the extant literature about the diagnosis and treatment of pediatric bipolar disorders. The four sections of these guidelines include diagnosis, comorbidity, acute treatment, and maintenance treatment. These guidelines are not intended to serve as an absolute standard of medical or psychological care but rather to serve as clinically useful guidelines for evaluation and treatment that can be used in the care of children and adolescents with bipolar disorder. These guidelines are subject to change as our evidence base increases and practice patterns evolve.

Section snippets

Limitations of DSM-IV Criteria

There is continued debate over the appropriateness of DSM-IV criteria for classifying BPD in children and young adolescents (Biederman et al., 2000a, Findling et al., 2001). For these guidelines, we have used DSM-IV criteria, acknowledging that the current DSM-IV criteria for mania were developed for adults and are frequently difficult to apply to children. Identifying episode onset and offset can be difficult because many children with BPD present with frequent daily mood swings that have been

SECTION II: ACUTE PHASE MEDICATION TREATMENT FOR BPD

These medication treatment algorithms were developed for the acute phase treatment of children and adolescents ages 6 to 17 years who meet DSM-IV criteria for BPD-I, manic or mixed episode. In the development of this algorithm, the consensus panel established four levels of evidence (A-D) that provided the guiding principle for the stages and branching within the treatment algorithm. These levels were as follows: level A data consisted of randomized, controlled clinical trials in children;

Stage 1: Monotherapy

Monotherapy with the traditional mood stabilizers lithium, divalproex, and carbamazepine and the atypical antipsychotics olanzapine, quetiapine, and risperidone was determined to be first-line treatment. Although lithium has had the most controlled study in children and adolescents with BPD (Brumback and Weinberg, 1977, DeLong, 1990, Geller et al., 1998a, Gram and Rafaelsen, 1972, Lena et al., 1978, McIntyre et al., 2003), some limitations include small sample size and methodological problems.

Stage 1: Mood Stabilizer Plus Atypical Antipsychotic

For children with BPD-I, manic or mixed with psychosis, it was recommended that initial treatment should be a combination of a traditional mood stabilizer (lithium, divalproex, or carbamazepine) and an atypical antipsychotic. As evidence, lithium plus an adjunctive antipsychotic in an open trial (Kafantaris et al., 2001a) (level C) was shown to demonstrate significant improvement for adolescents with acute mania and psychosis. Divalproex plus an atypical antipsychotic or carbamazepine plus an

SECTION III: TREATMENT OF COMORBID PSYCHIATRIC DISORDERS

As described in the section on assessment, most children and adolescents with BPDs have other coexisting (comorbid) psychiatric disorders, particularly ADHD, oppositional defiant disorder, conduct disorder, anxiety disorder, and, during adolescence, substance abuse. In this section, the treatment of these comorbid disorders is described. However, it is important to emphasize that there are very few controlled studies for the treatment of comorbid disorders in youths with BPD and that almost all

SECTION IV: MAINTENANCE/CONTINUATION TREATMENT

The basic goals of maintenance treatment include prevention of relapse and recurrence; reduction of subthreshold symptoms, suicide risks, affective cycling, and mood instability; reduction of vocational and social morbidity; and promotion of wellness. At present, it appears that the agents that help patients get well are the same ones that keep them well. Whereas lithium, divalproex sodium, and carbamazepine have been the agents most commonly used to treat children and adolescents with BPD (

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    Disclosure: Dr. Kowatch has received research support from Astra-Zeneca and Bristol-Myers Squibb, is on the advisory boards of GlaxoSmithKline and Janssen, and is on the speaker's bureaus of Abbott, AstraZeneca, and Janssen. Dr. Wagner has received research support from Abbott, Eli Lilly, Forest Laboratories, GlaxoSmithKline, Organon, and Pfizer; is on the advisory boards of Abbott Laboratories, Bristol-Myers Squibb, Cyberonics, Eli Lilly, Forest Laboratories, GlaxoSmithKline, Janssen, Jazz Pharmaceuticals, Novartis, Ortho-MacNeil, Otskua, Pfizer, UCB Pharma, and Wyeth-Ayerst; and serves on the speaker's bureaus of Abbott Laboratories, Eli Lilly, Forrest Laboratories, GlaxoSmithKline, Janssen, Novartis, and Pfizer. Dr. Findling has received research support from Abbott, AstraZeneca, Bristol-Myers Squibb, Celltech-Medeva, Forest, Johnson & Johnson, Eli Lilly, New River, Novartis, Otsuka, Pfizer, Shire, Solvay, and Wyeth and is a consultant for AstraZeneca, Best Practices, Bristol-Myers Squibb, Forest, GlaxoSmithKline, Johnson & Johnson, Eli Lilly, New River, Novartis, Otsuka, Pharmastar, PPD, Pfizer, and Shire. The other authors have no financial relationships to disclose.

    WORKGROUP MEMBERS/CONTRIBUTORS

    David Axelson, M.D., Department of Psychiatry, University of Pittsburgh Medical Center, Western Psychiatric Institute and Clinic, Pittsburgh; Joseph Biederman, M.D., Clinical Research Program in Pediatric Psychopharmacology, Massachusetts General Hospital, and Harvard Medical School, Boston; Gabrielle Carlson, M.D., Department of Psychiatry, Stony Brook University-Putnam Hall, Stony Brook, NY; Kiki Chang, M.D., Pediatric Mood Disorders Clinic, Stanford University School of Medicine, Stanford, CA; Kristen Clausen, Child and Adolescent Bipolar Foundation member; Dorie Geraci, M.S., R.N., Child and Adolescent Bipolar Foundation member; Melissa P. DelBello, M.D., Bipolar and Psychotic Disorders Research Program, University of Cincinnati College of Medicine; Paul E. Keck, Jr., M.D., Department of Psychiatry, University of Cincinnati College of Medicine; Ellen Leibenluft, M.D., Mood and Anxiety Program, National Institute of Mental Health, National Institutes of Health/DHHS, Bethesda, MD (Dr. Leibenluft participated in this meeting in a personal capacity and not as a representative of NIH); Robert Hirschfeld, M.D., Department of Psychiatry and Behavioral Sciences, University of Texas-Medical Branch, Galveston; Vivian Kafantaris, M.D., Department of Psychiatry, Zucker Hillside Hospital, Glen Oaks, NY; Demitri Papolos, M.D., Albert Einstein College of Medicine, Bronx, NY; Mani Pavuluri, M.D., Center for Cognitive Medicine, University of Illinois at Chicago; Mark Riddle, M.D., Department of Psychiatry and Behavioral Science, Johns Hopkins Hospital, Baltimore; Russell Scheffer, M.D., Children's Hospital of Wisconsin, Milwaukee; Lori Wiener, Ph.D., Child and Adolescent Bipolar Foundation member, Evanston, IL; Elizabeth Weller, M.D., University of Pennsylvania, Children's Hospital of Philadelphia; Janet Wozniak, M.D., Pediatric Psychopharmacology Unit, Psychiatry Service, Massachusetts General Hospital, Boston.

    Dr. Gaye Carlson provided very helpful professional support and Mrs. Diane Norton provided invaluable administrative assistance for this project.

    This project was sponsored by the Child and Adolescent Bipolar Foundation and supported by unrestricted educational grants from Abbott Laboratories, AstraZeneca Pharmaceuticals, Eli Lilly and Company, Forest Pharmaceuticals, Janssen Pharmaceutical, Novartis, and Pfizer.

    Article Plus (online only) materials for this article appear on the Journal's Web site: www.jaacap.com.

    Workgroup members/contributors are listed before the references.

    Correspondence to Dr. Kowatch, P.O. Box 570559, 7261 Medical Science Building, 231 Albert Sabin way, Cincinnati, OH 45267-0559; e-mail: [email protected].

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