2019/01/01 by Shiv Gautam, Akhilesh Jain, Manaswi Gautam +2 · 1 citation
Medicine · Psychology · Biochemistry, Genetics and Molecular Biology · #Bipolar Disorder and Treatment #Child and Adolescent Psychosocial and Emotional Development #Genetics and Neurodevelopmental Disorders
paper · doi:10.4103/psychiatry.indianjpsychiatry_570_18
openalex publication_date 2019/01/01 · openalex created_date 2025/10/10 · openalex updated_date 2026/08/01
INTRODUCTION According to the census of India, 40% of individuals are children below 16 years of age. There is a paucity of prevalence studies of mental disorders in children and adolescents. There are some community studies who have reported prevalence rates of 9.4% in children aged 8–12 years, 12.5% in children aged 0–16 years, and 1.81% in adolescents aged 12–16 years. Bipolar affective disorder (BPAD) has been recognized in children since 1990; however, there is active controversy whether it could occur before the age of 12 years. Some robust Indian studies have reported 3%–4% prevalence of mood disorders in children and adolescents. Lifetime prevalence rates of BPADs in this age group have been calculated 2.1% equal in males and females. These disorders are often associated with comorbid disorders such as anxiety disorders, attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorders (CDs). Some authors feel that bipolar disorders often start in adolescents with an episode of major depression, chronic fluctuating abnormalities of mood overactivity, cognition, and conduct disturbances. In the early stage, presenting symptoms are nonspecific and not limited to mood spectrum. ASSESSMENT AND EVALUATION Usually, the diagnoses in children are difficult because of commonly associated comorbidities. Children present with atypical or mixed features such as labile mood, irritability, behavioral problems, and rapid cycling course. Some may have school problems such as fighting substance abuse and sexual behavior with nonepisodic and chronic course. Adolescent presentation may be mood incongruent, bizarre, and/or paranoid, which may make the diagnosis difficult. Normal imaginative play, overactivity, boastfulness, and grandiosity should not be mistaken for child BPAD. The assessment of children for BPAD should be done as follows: Screening One should look for clear periods of low moods with emphasis in context in which the symptoms occur. Family history of mood disorders, substance use disorders along with presence of any other stressors must be explored. Diagnostic criterion The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-V) or International Classification of Diseases, 10th Revision Criterion is often used. Symptoms of BPAD (irritability/grandiosity/persistent sadness or low mood/loss of interests and/or pleasure, low energy, sleep and appetite disturbances, poor concentration or indecisiveness low self-confidence, suicidal thoughts and acts guilt or self-blame, and agitation or psychomotor retardation) should be present on the most days, most of the time for at least 2 weeks. Instruments for evaluation In case of difficulty or clarity, some instruments which can be used are severity rating using the Child Depression Inventory or Childhood Depression Rating Scale–Revised, Kiddie Schedule for Affective Disorders and Schizophrenia, and Mini-International Neuropsychiatric Interview for Children and Adolescents for the assessment of depression. Evaluation of comorbidity Comorbid disorders such as anxiety disorders, ADHD, ODD, and CDs may influence treatment decisions and also help in understanding long-term course, and hence, they should be evaluated and appropriate diagnosis should be made. FORMULATING A TREATMENT PLAN If possible, the diagnoses should establish using structured instrument for assessment and one should monitor the symptom patterns prospectively by providing a diary to record symptoms to the parents or caregivers of the patients. Baseline symptoms of mania or depression can be recorded using appropriate scales to be more objective (Young Mania Rating Scale/Children's Depression Rating Scale and global impression of the clinician). Baseline height, weight, waist circumference, pulse electrocardiography, blood pressure, and appropriate baseline blood tests such as complete blood count, blood sugar, lipid profile, urea electrolytes, creatinine, and liver function tests may be recorded in case of female adolescents’ serum prolactin. Treatment has to be planned according to the presentation of BPAD. Treatment for mild depression does not usually require medication. It will depend on the availability of psychological therapies, behavior therapies, counseling services, and family therapy. In some settings, medication and psychosocial management is provided simultaneously. For moderate depression, a combination of antidepressant and psychotherapy is recommended. For severe depression, psychopharmacological management with cognitive behavior therapy (CBT) and family therapy is advisable. For manic symptoms of BPAD, treatment can be initiated with low-dose antimanic agents and mood stabilizers. Guiding principles for treatment plan include: Begin with less, go slow, and monitor efficacy and adverse reactions Monotherapy is ideal; however, multiple medications are often required in the severely ill Allow adequate trial of treatment in children who are generally more ill and will often require longer periods of treatment before responding. Adequate time for such trials could be 8 weeks in BPAD patients Outcome should be monitored in outpatient department as well inpatient department patients settings Family must be educated regarding proper compliance of the treatment in case long term treatment is required. CHOICE OF TREATMENT SETTINGS Invariably, it is preferable to treat youngsters in their family environment; however, some acute cases may require hospitalization. Appropriate consent should be taken from parents/caregivers preferably; they must stay with the patient in the inpatient setting. PHARMACOLOGICAL TREATMENT General principles As children and adolescents are more likely to develop metabolic side effects of medications used to treat bipolar disorder, specially with atypical antipsychotics, a judicious use is recommended and polypharmacy needs to be avoided as far as possible. Growing evidence of increased risk of cardiovascular risk in this population emphasizes that lifestyle management including dietary regulation, substance use, smoking, and physical activity must be implemented and encouraged along with pharmacological and psychological interventions. A minimum period of 4–6-week trial of adequate dose for each medication (8 weeks in case of lithium) is recommended to ensure the effectiveness of medication. Key points of pharmacotherapy Patients and caregivers’ preference must be taken into account wherever possible in guiding the treatment Psychological interventions should be preferred over pharmacological treatment unless the latter is necessary Olanzapine, quetiapine, and risperidone are the antipsychotics of choice for the treatment of mania Fluoxetine is most preferred antidepressant in treating bipolar depression and only in combination with the atypical antipsychotic olanzapine In case of long term treatment, lithium is the most preferred medication and should be used first line. In case of mania, tapering and discontinuation of antidepressant is advised. OVERVIEW OF PHARMACOTHERAPY Pharmacotherapy is the mainstay of treatment for children and adolescents with bipolar affective disorder. Following principles should be used to select drug of choice: Scientific evidence of effectiveness Phase of illness Subtype of disorder (psychosis, mixed episode, and rapid cycling) Adverse effect profile with respect to the particular patient Previous treatment response history Possibly, also a family member's history of medication response. CHOICE OF MEDICATION Types of medication Pharmacological management of BPD in children and adolescent can broadly be categorized into four main classes of medications, namely mood stabilizers including anticonvulsant, atypical antipsychotics, anticonvulsant drugs, and anti-depressants. Different types of medications and combinations are used depending on the phases of illness (mania/hypomania/depression/mixed) and response to medicine. Certain amount of risk of adverse effect is associated with all classes of medications used in this age group. Family members and patients should be given detailed overviews about such risk factors, and risk versus benefit in this regard should also be discussed. Informed consent must be obtained before starting medication. Rapid cycling (4 or more acute episodes in a year) Look for other conditions which may cause rapid cycling such as substance abuse, hypothyroidism and treat accordingly. Gradually stop antidepressant Treatment should be targeted according to manic or depressive episodes. Many patients may require the combination of mood stabilizers and antipsychotics. MAINTENANCE TREATMENT It is recommended that the treatment that improves the patents in the acute phase of treatment also helps in maintenance and hence should be continued. Lithium, divalproex, olanzapine, and quetiapine are the most commonly used medications in maintenance therapy in children and adolescents. However, it is better to prefer mood stabilizers over SGA for maintenance treatment due to their high potential to produce notable side effects [Tables 1–15] and [Figures 1–3].Table 1: Acute management of maniaTable 2: Acute management of bipolar depressionTable 3: Maintenance treatmentTable 4: Pharmacological options for behavior disorder in children and adolescentsTable 5: Commonly used medications for behavior disorder in children and adolescentsTable 6: Monitoring of lithium and valproate/divalproex treatmentTable 7: Therapeutic blood monitoringTable 8: GoalTable 9: Risk factors for relapseTable 10: Monitoring medication in child & adolescent BPADTable 11: Side effects of medications and their managementTable 12: Measures to improve medication complianceTable 13: Common coexisting psychiatric disorder with BADTable 14: General principle of management of comorbid psychiatric disordersTable 15: Differentiating symptoms of BPAD and attention-deficit hyperactivity disorderFigure 1: Treatment Algorithm for Acute mania/mixed maniaFigure 2: Treatment Algorithm for Acute depressive episode (if not on lithium/valproate)Figure 3: Treatment Algorithm Acute depressive episode (if taking lithium/valproate)In case of BPD with psychotic symptoms, it is better to avoid long-term use of antipsychotics due to their side effect profile and it is recommended to withdraw SGA gradually after 12 weeks of symptom remission. Medication discontinuation should be considered by gradual tapering only after a patient has achieved remission for minimum 12 months or more. Special consideration should be given if patient has suicidal behavior, Increased aggression and psychosis. Sometimes, treatment may have to be continued even longer or lifelong. Side effects and their management Most of the side effects of antipsychotics medication and their management has largely been documented in chapter of Childhood onset Schizophrenia which may be referred for further reading. However, following precautions are advised to avoid such undesirable effects. Children and adolescents have less tolerance for antipsychotics in comparison to adults. While treating this group of population, we should look for presence of Extrapyramidal symptoms(EPS), increase in prolactin and increase in weight. It is advised that: Provide adequate information to patients and family in deciding treatment choice Family preference should be considered while choosing Antipsychotics Aim of antipsychotic treatment is to target symptoms. Star with low dose and monitor the dose depending on response Prefer Mono therapy Poly pharmacy should be used in case of nonresponse with monotherapy. Indicated adequate trial period with one drug should be given before changing the medication. Review the dose of drug and side effect profile regularly. TREATMENT OF COMORBID PSYCHIATRIC DISORDERS Pediatric-onset bipolar disorder (BPD) rarely occurs in the absence of comorbid conditions. The occurrence of comorbid disorders complicates both the accurate diagnosis of BPD and its treatment. Youths with BPD are among the most impaired population, and the presence of comorbidity intensifies disability, complicates treatment, and probably worsens the prognosis in this population.1 ATTENTION-DEFICIT HYPERACTIVITY DISORDER The response to lithium has been reported to be less robust in the presence of ADHD comorbidity in youth with BPD, suggesting that this subgroup of BPD may constitute a unique genetic subform with a differential treatment response. In youngsters with BPD, comorbid ADHD could be addressed selectively with the anti-ADHD armamentarium but only after mood stabilization. The stimulants have been reported to be efficacious in treating comorbid ADHD without precipitating (hypo) mania in mood-stabilized BPD youth in two controlled trials. A controlled trial of stimulants as an adjunctive therapy for ADHD in BPD youth with manic symptoms stabilized on divalproex found mixed amphetamine salts to be safe and efficacious for the treatment of ADHD in the context of BPD. Another evidence reported that in youth stabilized with a stable dose of at least one mood stabilizer, concomitant treatment with methylphenidate improved ADHD in a dose-dependent manner without destabilization of mood. Furthermore, an open trial of the nonstimulant anti-ADHD agent bupropion in adults with predominately mood stabilized bipolar II disorder and ADHD reported a significant improvement in ADHD without activation of These that the treatment for BPD needs to ADHD treatment and in stimulants and may be DISORDER Treatment of is behavioral in comorbid with other psychiatric conditions and pharmacological treatment of the comorbid disorder often symptoms of the risperidone is the most atypical antipsychotic for behavior disorder trials that risperidone can be for the in both and long-term is the other most atypical antipsychotic for in In youth with and ADHD who to to methylphenidate the of quetiapine a dose has been to be in symptoms of and and studies that divalproex is efficacious for the treatment of mood and in children and adolescents with DISORDERS that for BPD with mood stabilizers not generally treat anxiety disorders and that treatment of anxiety disorders with can the BPD, the pharmacological to bipolar children with comorbid anxiety disorders needs to be As BPD and anxiety disorders to of the comorbid is for proper treatment and for may be in the presence of comorbid anxiety because they have a more in this disorder. of anxiety disorders children with BPD by and children with a BPD diagnosis are from the trials of treatment for both depression and In mood is the before anxiety are DISORDERS While treating comorbid disorders such as bipolar disorder and should a psychosocial and medication should be considered in comorbid adolescents. There is evidence that pharmacological interventions are for youth with and BPD. studies have reported that mood lithium and substance use in bipolar A of treatment with lithium in youth with affective and substance reported a significant in the of as well as a significant increase in global In a open trial of in adolescent with and mood symptoms not using the significant improvement in use and affective symptoms treatment management of treatment therapy therapy is an treatment for the treatment of depression not to antidepressant It has to be used in child and adolescent caregivers have to be if is required for a given the of the caregivers have to in to the treating and after by it can be as A of usually required are However, it can be by the treating and are the reported in disorders recommended in severe cases of illness other treatment not In child population, has been in some studies in with Most patients from major depression and patients with bipolar depression. has a of some and behavior therapy Bipolar disorder in children and adolescents of the treatment is and necessary adjunctive treatment to pharmacological interventions for bipolar disorder in children and adolescents. bipolar disorder is by chronic and mood and long-term including poor poor of poor with family and in and and suicidal limited efficacy and side effects of pharmacological treatment, the of psychosocial treatment has been more by interventions such as adjunctive and family to symptoms, and and prognosis of bipolar The psychosocial also on to their mood and for the of A treatment with psychosocial is There are psychosocial treatment to which will be group psychotherapy family treatment for adolescents and for adolescents therapy for adolescents Child and for bipolar disorders in adolescents psychotherapy psychosocial TREATMENT has been for adolescents with mood disorders in adolescents. is for the age group of years with mood disorder and of to and over a period and and it will the and and to improve and to with the illness and also improves of the therapy which on understanding of the symptoms of the better compliance for of mood episodes and and The family for the family and not only the patient and of and It also and for The of is to symptoms by increased of to with the of and improved family and The of for mood disorders is to of patients and parents regarding the and information about the and symptoms, pharmacological and treatment options and associated and treatment at of medication early of episodes or comorbid or psychiatric and of substance and group psychotherapy for children with bipolar disorder. and family to target affective symptoms and associated and parents and children about the illness and their family with other and in symptom management which effects regulation, and A of are with parents and children in both group and of with family In of and of for patient and their family and with school about the illness and and including and management is a of psychosocial interventions since and as both factors and as of any episodes of Children are to develop a of they have to and in each of four and which can be used to are also for their and and of AND TREATMENT is a adjunctive psychosocial for the age group of years with bipolar disorders and their and with and therapy. The is a treatment and and it has also been to a group which of and child group and is In both therapy is structured that the as follows: A can it thoughts and in the be a and lifestyle for parents can we this to in the and a behavioral and child and in and behavior therapy for adolescents with A of is the on the for adolescents with The therapy a of the of It has two family for the family which and of regulation, and psychotherapy for the therapy on with and by Patients who and depressive symptoms after the therapy. AND the of has been for The a for the in and in and that The is treatment which family psychotherapy which on and sleep and with psychosocial stressors an and also of proper medication compliance and of may and there are on the of the maintenance phase of There however, some suggesting that if early and the acute it may the time to The for adolescents’ on medication mood sleep regulation, and family The therapy of 12 with the with the family in two and one to The of the limited for the of the acute phase of bipolar depression as adjunctive treatment but not for the maintenance phase be The that interventions of group to a However, this is to manic episodes and to patients at the of the who have achieved remission before the has DISORDER The presence of and with Bipolar in Children and Adolescents is also and at severe which needs to be addressed mood disorders to be to psychiatric comorbidity with more severe episodes. and management of associated may help the severity of and of each episode in bipolar BPD to lithium are less in the presence of comorbid are more and safe for the treatment of associated ADHD after the manic episode is The management of BPD with and lithium in the of to in disorder with mood is less with for adverse effects. The ADHD comorbidity is often associated with BPD. A prevalence of anxiety disorders is in BPD. These patients more poor response to treatment, and and course. bipolar disorder occurs in the absence of comorbid conditions. The comorbidity complicates both the diagnosis and Comorbid disorders may have a significant on the of BPD and appropriate treatment may to improved and of comorbid conditions. If are not of symptoms could to to of symptoms, and of The first consideration that the should have in in the of a treatment plan for child and adolescents with comorbidity is the of the of PSYCHIATRIC ADHD including disorder disorder disorder disorders Mental disorder on psychiatric comorbidity in that is a rapid mixed manic that may be associated with or As both and are their severe and needs to be The and mania is with the comorbidity and major depression and bipolar of depression. The often or behavior and family members which with that manic episode of such as and school rates of are reported in and this comorbidity has a more and with high rates of Furthermore, is reported to be severe in patients of As BPAD may have comorbid and behavior of it is advised to antipsychotics, the of atypical antipsychotics and their efficacy has been The antimanic agent lithium has been found to be agent in patients. The also that antipsychotic medication such as is in aggression in patients. of side effects of antipsychotics, the use of atypical antipsychotic agents in the treatment of with behavior has been One trial that term and long term treatment with quetiapine is safe and well In one the treatment with olanzapine in the improvement of behavior but also associated with disorder symptoms such as thoughts and of in severe can a bipolar symptoms of activity or thoughts in BPAD can have effect on treatment of the anxiety disorders and has been reported to poor response to treatment has been found to be and should be used with any of the pharmacological to disorder The reported rates of comorbidity in patients with have from to of is in who a diagnosis of before the age of years as to who a evidence is for the management of comorbid and may be in treating symptoms. studies that may be for treating symptoms such as and In one efficacy in the treatment of symptoms or and in adults. disorders In the presence of comorbid the patients an age at onset and increased severity of with a of Treatment response to of patients found to be less robust with rates of side effects to both medication and due to an atypical response and of side it is to and pharmacotherapy at a dose and in limited on the management of with that antipsychotics and and mood stabilizers and are in In a of acute atypical antipsychotic trials in the that and robust antimanic response to atypical antipsychotic use olanzapine, quetiapine, or in the presence of are well and efficacious in treating and a antimanic response in with and is found to be and efficacy profile for and aggression with of side effects Patients with who are significant should be treatment with the atypical antipsychotics to target their as well as their bipolar disorder. Patients with and behavioral symptoms associated with should also be with a other mood stabilizers should be as The use of other medications and/or psychosocial treatment that other symptoms and should be taking into account that some medications may the mood. If patients should be referred to an appropriate to the treatment of patients with and mental are to for patients with and For patients with or in to pharmacotherapy that both disorders such as divalproex, and should be patients with significant may be after mood with divalproex, or other mood stabilizers. and of There are of