Bipolar disorder typically begins during mid-adolescence through the mid-20s. In many children, the initial manifestation is one or more episodes of depression. (See also Bipolar Disorders in adults.)
Bipolar disorder is rare in children. In the past, bipolar disorder was diagnosed in prepubertal children who were disabled by intense, unstable moods. However, because such children typically progress to a depressive rather than bipolar disorder, they are now classified as having disruptive mood dysregulation disorder.
Etiology
Etiology of bipolar disorder is unknown, but heredity is involved. Dysregulation of serotonin and norepinephrine may be involved, as may a stressful life event.
Certain drugs (eg, cocaine, amphetamines, phencyclidines, certain antidepressants) and environmental toxins (eg, lead) can exacerbate or mimic the disorder. Certain disorders (eg, thyroid disorders) can cause similar symptoms.
Symptoms and Signs
The hallmark of bipolar disorder is the manic episode. Manic episodes alternate with depressive episodes, which can be more frequent. During a manic episode in adolescents, mood may be very positive or hyperirritable and often alternates between the 2 moods depending on social circumstances. Speech is rapid and pressured, sleep is decreased, and self-esteem is inflated. Mania may reach psychotic proportions (eg, “I have become one with God”). Judgment may be severely impaired, and adolescents may engage in risky behaviors (eg, promiscuous sex, reckless driving).
Prepubertal children may experience dramatic moods, but the duration of these moods is much shorter (often lasting only a few moments) than that in adolescents.
Onset is characteristically insidious, and children typically have a history of always being very temperamental and difficult to manage.
Diagnosis
Diagnosis of bipolar disorder is based on identification of symptoms of mania as described above, plus a history of remission and relapse.
A number of medical disorders (eg, thyroid disorders, brain infections or tumors) and drug intoxication must be ruled out with appropriate medical assessment, including a toxicology screen for drugs of abuse and environmental toxins. The interviewer should also search for precipitating events, such as severe psychologic stress, including sexual abuse or incest.
Prognosis
Prognosis for adolescents with bipolar disorder varies. Those who have mild to moderate symptoms, who have a good response to treatment, and who remain adherent and cooperative with treatment have an excellent prognosis. However, treatment response is often incomplete, and adolescents are notoriously nonadherent to drug regimens. For such adolescents, the long-term prognosis is not as good.
Little is known about the long-term prognosis of prepubertal children diagnosed with bipolar disorder based on highly unstable and intense moods.
Treatment
For adolescents and prepubertal children, mood stabilizers are used to treat manic or agitated episodes, and psychotherapy and antidepressants are used to treat the depressive episodes.
Mood stabilizers (see table Selected Drugs for Bipolar Disorder) roughly fall into 3 categories:
All mood stabilizers have a potential for troubling and even dangerous adverse effects. Thus, treatment must be individualized. Furthermore, drugs that are highly successful during initial stabilization may be unacceptable for maintenance because of adverse effects, most notably weight gain.
Antidepressants may trigger a switch from depression to mania; therefore, they are usually used with a mood stabilizer.
Selected Drugs for Bipolar Disorder*
Drug |
Indication |
Starting Dose† |
Maintenance Dose† |
Comments |
Lithium |
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|
Lithium extended-release‡,§, in adolescents ≥ 12 years |
Acute mania and maintenance |
— |
450–900 mg twice a day |
Dose titrated to a blood level of 0.8–1.2 mEq/L (or mmol/L) |
|
Lithium, immediate-release‡,§, in adolescents |
Acute mania and maintenance |
200–300 mg three times a day |
300–600 mg three times a day up to 2400 mg |
The maximum daily dose is 40 mg/kg |
Antipsychotics |
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|
Aripiprazole§ in children ≥ 10 years |
Acute mania Psychosis |
2–5 mg once a day |
Up to 30 mg once a day |
Limited experience in children |
|
Chlorpromazine in children > 5 years‡,§ |
Acute mania Psychosis |
0.6–1.5 mg/kg every 6 hours up to 200 mg/day |
— |
Rarely used (in children who do not respond to newer drugs) because newer drugs have a more favorable adverse effect profile |
|
Lurasidone in children > 10 years |
Bipolar depression |
20 mg once a day |
Up to 80 mg/day |
— |
|
Olanzapine in children > 13 years§ |
Acute mania Psychosis |
2.5–5 mg once a day |
Up to 10 mg twice a day |
Causes weight gain, which may limit use in some patients |
|
Olanzapine/fluoxetine fixed combination in children > 10 years‡,§ |
Bipolar depression |
3 mg/25 mg once a day |
Up to 12 mg/50 mg once a day |
Limited experience in children |
|
Paliperidone in children > 12 years ‡,§ |
Acute mania Psychosis |
3 mg once a day |
Up to 3 mg twice a day |
Closely related to risperidone Very limited experience in children |
|
Quetiapine, immediate-release, in children > 10 years§ |
Acute mania Psychosis |
25 mg twice a day |
Up to 200 mg twice a day |
Causes sedation that may limit dose increases |
|
Risperidone in children > 10 years§ |
Acute mania Psychosis |
0.5 mg once a day |
Up to 2.5 mg/day |
Maintenance dose highly variable Doses up to 6 mg/day have been studied, but they provide no additional benefit and increase risk of neurologic adverse effects |
|
Ziprasidone in children > 10 years§ |
Acute mania Psychosis |
20 mg once a day |
Up to 40 mg twice a day |
Very limited experience in children |
Anticonvulsants |
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|
Carbamazepine |
Acute mania and mixed episode |
200 mg twice a day |
Up to 600 mg twice a day |
Metabolic enzyme induction, possibly requiring dose adjustments May cause Stevens-Johnson syndrome, especially in patients with HLA-B*1502 genotype, which is most common in patients of Asian ancestry, who should probably have HLA genotyping |
|
Divalproex |
Acute mania |
5 mg/kg two or three times a day |
Up to 10–20 mg/kg three times a day |
Dose titrated to a blood level of 50–125 mcg/mL |
|
Lamotrigine |
Maintenance |
25 mg once a day |
Up to 100 mg twice a day |
Requires that dosing guidelines in the package insert be followed closely |
|
*These drugs pose a small but serious risk for a wide variety of major adverse effects. Therefore, benefits must be carefully weighed against potential risks. |
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†Dose ranges are approximate. Interindividual variability in therapeutic response and adverse effects is considerable. This table is not a substitute for the full prescribing information. |
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‡These drugs have not been studied in children. For dosing in children under 12 years of age, see the prescribing information. |
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§These drugs increase the risk of weight gain, negative effects on the lipid profile, increases in glucose and prolactin levels, and QT prolongation. |
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Key Points
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Bipolar disorder is characterized by alternating periods of mania, depression, and normal mood, each lasting for weeks to months at a time.
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Bipolar disorder typically begins during mid-adolescence through the mid-20s; it is rare in children.
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Typically, onset is insidious; children have a history of being very temperamental and difficult to manage.
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In adolescents and prepubertal children, treat manic or agitated episodes with mood stabilizers and depressive episodes with psychotherapy and antidepressants (usually with a mood stabilizer).
