RECOGNIZING AND TREATING BIPOLAR DISORDER EARLY IS KEY TO AGOOD OUTCOME

Vast numbers of children in the US are poorly treated is apublic health travesty of extraordinary proportions.  Many factors combine to make thisparticularly troublesome.

1.       Recent epidemiological data of K. Merikangas etal 2010 indicate that 2.7% of children and adolescents in the US have bipolardisorder.  This begins with a depressiveepisode in one half or more of children. Therefore, one is talking about a lack of good information for more thana million children in the US.

2.       Depression is associated with considerabledysfunction and disability.

3.       Some two thirds of the weeks of follow up of mania in children are associated with symptomatic depression or mania.

4.       Depression is a major cause of suicide, which is increasing in this adolescent population.

5.       Childhood onset of bipolar disorder in adults in our network and that of the STEP-BD is associated with a more poor outcome inadults compared to those with adult onsets.

6.       Duration of time from illness onset to firsttreatment of depression or mania is an independent risk factor for a pooroutcome in adulthood, yielding more time and severity of depression, moreepisodes, and less time euthymic.

So bipolar disorder is a devastating illness for greatnumbers of children that can carry a poor prognosis for a variety ofdifficulties later in life if it is not adequately treated.

Given this set of immediate and longterm problems ofchildhood onset bipolar depression in the relative absence of  the best type of treatment information(randomized, double-blind, placebo-controlled clinical trials) how shouldparents, physicians, and clinicians proceed. A number of important principles may form useful guidelines.

1.       If one employs the basis tenant of theHippocratic Oath of doing no harm, this paradoxically means engaging the childand family in treatment, since not treating will likely convey grave harm.

2.       One should use the safest and best toleratedtreatments first.

3.       Sometimes non-FDA approved treatments are neededfor bipolar depression in childhood. Approved treatments include: lurasidone (Latuda); lumaterperone(Caplyta); Vraylar; and lithium.

4.       Non-FDA approved treatment include: lamotrigine(Lamictal); oxcarbazepine (Trileptal) and carbamazepine (Tegretol; Equetro)

5.       Accurate diagnosis and longitudinal follow upare of great importance.

6.       Careful monitoring and follow up will facilitatethe evaluation of whatever treatments are undertaken and allow the developmentof optimal approaches for a given child.

7.       Education about the illness and honestinformation and informed consent about the current paucity of controlledstudies is an important place to start.

8.       Various forms of family education and therapyare available and should be pursued. These include:

a.       Family psychoeducation about illness recognitionand management.

b.       Family focused therapy (FFT) pioneered by DavidMiklowitz.

c.       Clinical Manual for Management of BipolarDisorder in Children and Adolescents. Edited by: Robert A. Kowatch, M.D.,Ph.D.,; Mary A. Fristad 

d.       For older children and adolescents, cognitiveand behavioral treatment (CBT), dialectable- behavior therapy (DBT),interpersonal and social rhythms therapy (IPSRT) should be considered.

9.       Parents with the help of their own physicians should optimize their own treatment (if they have an affective illness) and /or look after their own well being with as much family, friend, social, andadvocacy group support as they can acquire.

10.  One should recognize that psychopharmacological options are almost always needed,and that treatment recommendations by experts may be highly variable at thepresent time because of the limited treatment information available in theliterature. Current recommendations and treatment sequences may changedramatically as more information becomes available.

11.   In this respect, clinicians and parents shouldview the following ideas from this editor as highly provisional and preliminaryand to be reviewed and evaluated by the child’s treating clinicians based on assessment of the available and evolving literature and the child’s progress.  Please also re-read the caveat in the BNN masthead that the editor cannot be responsible for the quality ofthe material reported in the BNN which needs to be checked and affirmed by the treating physician.  Similarly, any preliminary ideas, strategies, suggestions, direct or implied recommendations by the editor of the BNN, must be affirmed and authorized by the appropriate treating physician of a child or adult patient who bears the medical responsibility for any treatments undertaken.