Bipolar: To Be or Not To Be… Pediatric Bipolar Update Stephen Grcevich, MD President and Founder, Family Center by the Falls Chagrin Falls, OH Department of Psychiatry Northeastern Ohio Universities College of Medicine Presented at: Children’s Hospital Medical Center of Akron August 20, 2010 E-mail: [email protected]Phone: (440) 543-3400 Twitter: @drgrcevich
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Bipolar: To Be or Not To Be… Pediatric Bipolar Update
Stephen Grcevich, MD
President and Founder, Family Center by the Falls Chagrin Falls, OH
Department of Psychiatry Northeastern Ohio Universities College of Medicine
Presented at: Children’s Hospital Medical Center of Akron August 20, 2010
Quetiapine total cholesteroltriglyceridesHDL cholesteroltriglyceride:HDL ratio
Risperidone triglyceridesAripiprazole No significant metabolic effects
Correll, CU et al., JAMA. 2009;302:1765–1773.
Diagnostic criteria for Bipolar Disorder:
A distinct period of elevated, expansive or irritable mood lasting at least one week in which three or more of the following are present (four if mood is only irritable):
Temper Dysregulation Disorder (TDD) with Dysphoria (proposed in
DSM-V): Characterized by severe recurrent temper outbursts in response to
common stressors
Temper outbursts are manifest verbally and/or behaviorally, such as in the form of verbal rages, or physical aggression towards people or property
The reaction is grossly out of proportion in intensity or duration to the situation or provocation
Responses inconsistent with developmental level
Temper outbursts occur, on average, three or more times per week.
Mood between temper outbursts is persistently negative (irritable, angry, and/or sad).
Negative mood is observable by others (e.g., parents, teachers, peers).
DSM-V Task Force, American Psychiatric Association, 2010
AACAP concerns about “TDD”
Diagnosis Is imprecise
Syndrome based on work in patients described as “SMD”
Invites criticism for “pathologizing” temper tantrums
Proposed criteria are almost certainly premature
Research hasn’t clarified boundaries between “TDD”, ADHD, Oppositional Defiant Disorder and developmentally acceptable behavior
More information needed on how the phenotype changes over the lifespan
American Academy of Child and Adolescent Psychiatry, March 30, 2010
What will kids with SMD/TDD look like in your clinic?
They have ADHD
They have difficulty with transitions
They tend to “ruminate”…indecisive, think too much about things, perseverate
They may experience some improvement in some settings from ADHD medication, but become more irritable, have more meltdowns at home
They have a higher than expected prevalence of anxiety disorders, but are probably subsyndromal for OCD
They’re prone to behavioral activation on SSRIs, often mistaken for mania, hypomania
AACAP Practice Parameters for Assessment and Treatment of Bipolar Disorder (2007)
Pharmacotherapy is the primary treatment in well-defined DSM-IV Bipolar I disorder
A comprehensive treatment plan, combining medications with psychotherapeutic interventions is needed to address the symptomatology and confounding psychosocial factors found in children and adolescents with bipolar disorder
J . Am. Acad. Child Adolesc. Psychiatry, 46:1, January 2007
FDA-approved medications for youth with Bipolar Disorder
Risperidone: Bipolar mania (10-17)
Aripiprazole: Bipolar mania (10-17)
Quetiapine: Bipolar mania (10-17)
Olanzapine: (labeling-consider other drugs first) Bipolar mania (13-17)
FFT (Family focused therapy) psychoeducation, communication enhancement training, and problem solving skills training-two year RCT indicated improvement in depressive sx. With bipolar disorder
DBT: One open label trial (N=10)
CFF-CBT: Open-label trial (N=34) with three year follow-up showed benefits of treatment were maintained
West A, Pavuluri M. Child Adolesc Psychiatric Clin N Am 18 (2009) 471–482
Take-home points:
Use of the term “Bipolar Disorder” in pediatric population should be reserved for mood episodes lasting four days or longer
A large subset of patients exists with chronic irritability, explosive outbursts, chronic negativism, long-term risk of ADHD, depression, differences in neural circuitry and cognitive flexibility. Little research is available to inform our treatment of them.
Careful evaluation and a comprehensive treatment plan developed by a fully trained child and adolescent psychiatrist, combining medications with psychotherapeutic interventions, are essential
Resources for pediatricians:
AACAP Bipolar Disorder Resource Center http://www.aacap.org/cs/BipolarDisorder.ResourceCenter
Child and Adolescent Bipolar Foundation http://www.bpkids.org/
Psychopharmacology of Pediatric Bipolar Disorder Expert Review of Neurotherapeutics http://www.medscape.com/viewarticle/724852 (Medscape membership required-membership, article free. Click on print version for summary tables of all studies)