Bipolar Disorder CLINICAL PEARLS • Bipolar disorder affects an estimated 2% of pediatric patients under age 21.1 • Pediatric bipolar disorder differs from the adult diagnosis with youth typically presenting with rapid fluctuations in mood and behavior. These symptoms are also often in combination with attention deficit hyperactivity disorder and/or disruptive behavior disorders. The difference between Bipolar Disorder Type I and II is the length of the manic episode and/or presence of marked impairment or hospitalization. Type I is when the manic episode lasts at least seven days and/or the child requires hospitalization. Type II is when the manic episode lasts four days and the child does not require hospitalization. Pediatric patients may also experience bipolar depression which may guide medications. *A diagnosis of bipolar disorder should not be given without a full psychological or psychiatric evaluation of the pediatric patient.
• There are no medications approved for children younger than age seven. FDA-approved medications will be preferred first line, but off-label medications can be used if comorbid diagnoses or favorable patient characteristics are present. • Ensure appropriate monitoring occurs if the child is prescribed medications with risk of metabolic changes, such as atypical antipsychotics, valproate and lithium. Also, the child who is prescribed an atypical antipsychotic should also be monitored for abnormal involuntary movements with the Abnormal Involuntary Movement Scale (AIMS). • Ensure family supports are present, including family psychoeducation and skill building. RATING SCALES • Child Mania Rating Scale-Parent Version2,3—age five–17 • Young Mania Rating Scale4,5—age 10–17 TREATMENT APPROACH Stage 1: Diagnostic Assessment.* Access to the AACAP Bipolar guidelines can be found here.6 Stage 2: Select an FDA-approved agent as monotherapy. Atypical antipsychotic agents approved for youths aged 10–17 are risperidone, aripiprazole, quetiapine, asenapine and lurasidone. Olanzapine, also an atypical antipsychotic, is approved for youths aged 13–17. Lithium is the only mood stabilizer approved for use in pediatrics, and its indication is for youths aged seven–17.
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