Bipolar disorder is one of the more serious psychiatric illnesses, with a lifetime prevalence of 2.4%. For up to half of the people with bipolar disorder, the illness begins at less than 13 years of age (very-early-onset bipolar disorder) or between 13 and 18 years of age (early-onset bipolar disorder). Early-onset versus late-onset bipolar disorder is associated with an elevated risk of suicidality, greater severity of depression and mania, a higher number of episodes, high level of comorbid anxiety and substance use, ultradian cycling, fewer days of euthymic mood, and an elevated risk of chronic illness course. In addition, the families of youth with bipolar disorder are under heavy strain, which can worsen the course of pediatric bipolar disorder.
Diagnosing bipolar disorder in children and adolescents can be challenging, as the presentation of symptoms may differ from those in adults. In addition, mood swings are a normal part of childhood and adolescence, making it difficult to carefully evaluate symptoms over time. Furthermore, pediatric bipolar disorder often coexists with neurodevelopmental comorbidities such as attention deficit hyperactive disorder, oppositional defiant disorder, conduct disorder, anxiety disorders, learning disabilities and less frequently, autistic spectrum disorder. It has been debated whether pediatric bipolar disorder and classic adult form of bipolar disorder represent the same illness. Evidence from neurological findings, overlap in comorbidities and longitudinal studies suggest a continuity between the juvenile and adult formal bipolar disorder.
Guidelines for Diagnosis
DSM V TR Criteria
Suggested screening question: Have there been times, lasting at least a few days, when you felt the opposite of depressed, when you were very cheerful or happy and this felt different from your normal self?
If yes, ask: During those times did you feel this way all day or most of the day? For how many days did this last and/or result in you being hospitalized? Did this ever cause you significant trouble with your friends or family, at school or work or in another setting?
There are three main types of bipolar disorder:
Bipolar I Disorder
The DSM-5 TR criteria for bipolar disorder include:
Bipolar I Disorder: It requires at least one manic episode, which may be preceded or followed by hypomanic or major depressive episodes.
Manic Episode: It is characterized by an elevated, expansive, or irritable mood lasting at least one week, along with additional symptoms such as increased energy, decreased need for sleep, and grandiosity.
Hypomanic Episode: It is similar to a manic episode but less severe and lasts at least four consecutive days.
Major Depressive Episode: It involves a depressed mood or loss of interest or pleasure in most activities, lasting at least two weeks.
NOTE: These episodes must not be better explained by other mental disorders.
Manic Episode
A. Inclusion: Requires at least three of the following criteria during a manic episode, lasting for a week or more.
B. Exclusion: The occurrence of manic and major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.
C. Exclusion: The episode is not due to the physiological effect of substances or other medical conditions. However, a manic episode that emerges during antidepressant treatment but persists beyond the physiological effect of treatment meets criteria for the diagnosis.
D. Modifiers
NOTE: Acute mania is a medical emergency and should be referred for urgent psychiatric assessment.
Bipolar II Disorder
DSM 5-TR Criteria
Depressive Episode:
Inclusions: Requires the presence of at least five of the following symptoms, which must include either depressed mood or loss of interest or pleasure (anhedonia), during the same two-week episode.
Patients may present with a history of manic, hypomanic, depressive, or mixed symptoms.
Guidelines for Screening and Assessment
Clinical Presentation:
Differential Diagnosis of Bipolar Disorder
ADHD:
Patients with ADHD present with symptoms of hyperactivity, impulsiveness and inattentiveness. Patients have difficulty sitting still, have a history of excessive restless energy, being continuously fidgety, moving from activities to activities and requiring repeated redirections. Patients have a history of poor concentration, short attention span and inability to focus and complete tasks. Patients are disorganized and forgetful. ADHD symptoms are present all day long, every day while symptoms of bipolar disorder mood lability are episodic in nature.
Oppositional Defiant Disorder:
Patient is defiant, refuses to follow directions, challenges authority figures. Patient does as he pleases. Patients with oppositional defiant disorder are reactionary when they do not get their way resulting in meltdowns, aggressive episodes lasting from few minutes to few hours.
Conduct Disorder:
Patient presents with a repetitive and persistent pattern of behavior in which basic rights of others or major age-appropriate societal norms or rules are violated. Patients bully, threaten or intimidate others. Patients often initiate physical fights and have used a weapon that can cause serious physical harm to others. Patients have a history of being physically cruel to people or animals. The patient has stolen. Patients might have a history of forcing someone into sexual activity or have deliberately engaged in fire-setting with an intention of causing serious damage. Patients have a history of deliberately destroying others’ property or have a history of breaking into someone else’s house building or car. Patients may have a history of running away from home overnight without permission or lying for personal gain.
Disruptive Mood Dysregulation Disorder:
Patient has a history of severe recurrent temper outbursts in response to common stressors, averaging at least three times per week, for at least one year. Outburst must occur in at least two distinct settings such as school or home, be severe in at least one setting, and begin before 10 years of age. Temper tantrums and behavioral outbursts are disproportionate reactions to the stimuli. Patients with disruptive mood disorder aggression disorder will not have hypomanic or manic symptoms.
Anxiety Disorders:
Intensifying of anxiety disorder may present in pediatric age group as escalating behavior difficulties, mood lability and aggressive behaviors.
Mood lability and aggressive behaviors are noticed in pediatric age groups with anxiety disorders when patients are unable to manage the anxiety symptoms and feel out of control.
PTSD:
Patient has an exposure to actual or threatened death, serious injury or sexual violation. The exposure can be firsthand or witnessed. Patients must experience at least one of the following intrusive symptoms for at least one month after the traumatic experience. Memories, flashbacks, nightmares, exposure distress and physiological reactions related to trauma.
Reactive Attachment Disorder, Disinhibited Type:
Patients have childhood experience of extremes of insufficient care, before age five years, that resulted in rare or minimal comfort seeking and rare minimal response to comfort. Patients have a lack of social and emotional responsiveness to others. They will have limited positive effects with episodes of unexplained irritability, sadness of fearfulness, which are evident during non-threatening interactions with caregivers. Patients may exhibit profoundly disturbed externalizing behaviors including violent behavior outburst.
Substance Use Disorder:
Mood lability and aggressive behaviors are as a result of substance abuse.
Bipolar Disorder Screening and Rating Scales
Call Your ACCESS Mental Health for Youth Hub Team for assistance:
Hartford Hospital Hub: 1-855-561-7135
Wheeler Clinic Hub: 1-855-631-9835
Yale Child Study Center Hub: 1-844-751-8955
Medication Guidelines
Second Generation Antipsychotic Mood Stabilizers:
Antiepileptics:
Initiate valproic acid at a dose of 250 mg/day in two divided doses. Titrate dose to a maximum range of 500 to 2000 mg/day. Monitor five therapeutic blood levels days to one week after. titration of doses to a therapeutic level between 50 and 100 mcg/mL. FDA approved for epilepsy for youth 10 years of age and older.
For children under age six years initiate therapy in 10 to 20 mg/kg/day in two-three divided doses not to exceed a dose of 35 mg/kg/day in 2-3 divided doses. For ages between 6-12 initiate therapy at 100 mg twice daily to be increased by 100 mg/day on a weekly basis for maintenance dose of 400 to 800 mg/day in two-three divided doses and not to exceed 1000 mg/day. Over 12 years of age initiate therapy in 200 mg twice daily and increase by 200 mg/day every week not to exceed 1000 mg/day for ages between 12 and 15 and over 1200 mg for ages over 15 years. Carbamazepine is FDA approved for children over six years of age for partial complex seizures please.
Initiate therapy at 25 mg once daily and titrated in a 25 mg increments every one to two weeks to a maximum dose of 200 to 300 mg/day and once or twice divided dosing. Safety and effectiveness are not established, and it is not approved by FDA for use in minors for bipolar disease. Compliance with lamotrigine is important. If dosing is missed for more than five days, then patient needs to be restarted from beginning. Patient needs to be educated regarding side effects of photosensitivity and Stevens-Johnson syndrome.
Dosing can be started at a dose of 15 to 20 mg/kg/day in two divided doses while in adults and it can be started at the dose of 300 mg/day in two divided doses. Titration of the dose needs to happen every five to seven days to achieve a therapeutic level of 0.6-1.2 mEq/L. FDA has approved lithium for bipolar disorder for children over age 12 years.
Antidepressants:
Patients with bipolar disorder may present with the most recent episode of bipolar I disorder or bipolar II disorder be a depressive episode or a mixed (mania, hypomania, or depressive symptoms) episode. In such a situation, antidepressants may form part of the regimen with mood stabilizers or a combination therapy of mood stabilizers. In such a situation, it is recommended that primary care providers seek consultation from ACCESS Mental Health for Youth or other psychiatric providers.
SSRI (Selective Serotonin Reuptake Inhibitors)
SNRI (Serotonin Norepinephrine Reuptake Inhibitors)
For dosing of antidepressants, please refer to the Depression toolkit on ACCESS Mental Health for Youth website. (insert hyperlink)
NOTE: It is strongly recommended that primary care providers seek consultation from ACCESS Mental Health for Youth or other child psychiatrists for any questions or concerns regarding assessment, treatment and medication management of patients presenting with bipolar disorder.
Medication trial 1: Monotherapy with FDA approved second-generation antipsychotics like risperidone, aripiprazole, quetiapine or olanzapine.
Medication trial 2: If trial with monotherapy second-generation antipsychotic does not alleviate symptoms after titrating for two to four weeks switch to another second-generation antipsychotic. Do not combine second-generation antipsychotics.
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If the above 2 medication trials do not work, then the patient may need a combination of medications. Patients may benefit from a combination of second-generation antipsychotic with lithium or a second-generation antipsychotic with antiepileptic mood stabilizers. This combination regimen with the guidance of ACCESS Mental Health for Youth child psychiatrist.
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If a patient presents with a mixed episode, then the patient may need a combination of a mood stabilizer with an antidepressant. Mood stabilizers can be combined with antidepressants like SSRIs or SNRIs.
It is imperative for primary care providers to understand that frequently bipolar disorder patients will also have significant depressive symptoms. It is important that a mood stabilizer may be used prior to or along with an antidepressant to address symptoms of depression or bipolar depression.
REMEMBER: ACCESS Mental Health for Youth can also help primary care providers connect their patients and families with child psychiatric and behavioral treatment services.
Practice Parameters:
National Institute of Mental Health (NIMH) – Bipolar Disorder in Children and Adolescence
Laboratory Work-up for Medication Management:
Significant Adverse Effects of Recommended Medications:
For second generation antipsychotic prescribers need to be mindful of weight gain, increasing BMI, metabolic syndrome, neuroleptic malignant syndrome, extrapyramidal side effects, prolactin level elevation, tardive dyskinesia. Prescribing antipsychotic requires completing AIMS every six months to a year.
For valproic acid prescribers need to be mindful of hepatotoxicity, PCOS with female patients, teratogenicity and auto induction of hepatic enzymes leading to a need higher dose of valproic acid needed to maintain therapeutic levels.
A lithium prescriber needs to be mindful of lithium toxicity due to increased blood levels of lithium due to compromised renal function, cardiovascular function and dehydration, hypothyroidism, and teratogenicity. Lithium is not metabolized and is excreted through kidneys. Therefore, to avoid toxicity NSAIDs should be avoided. It is also recommended to avoid diuretics, which will increase lithium levels and hence chances of lithium toxicity. It is important that patients taking lithium should hydrate appropriately.
For antidepressants, parents need education regarding black box warning.
Non-pharmacological Treatment
Therapy:
Patient and family need to be involved in therapy both individual and family system being involved to address psychosocial issues, along with interpersonal difficulties and improve patient’s self-esteem with social and coping skills. Family therapy to work on resetting familial hierarchy, empowering parents, and working on parenting skills. Positive parenting programs can be helpful.
Psychoeducation of parents regarding parents is of utmost importance for patient management.
ACCESS Mental Health for Youth Clinical Conversations Trainings
Family Resources
Books:
Websites:
Provider Resources
References