APA Practice Guidelines
4. Children and adolescents with bipolar
cont. from
The prevalence of
bipolar disorder in a community sample of children and
adolescents was 1%; an additional 5.7% had mood symptoms that met criteria for
bipolar disorder not otherwise specified. Although DSM-IV-TR criteria are used
to diagnose bipolar disorder in childhood and adolescence, the clinical features
of childhood bipolar disorder differ from bipolar disorder in adults.
Children
with bipolar disorder often have mixed mania, rapid cycling, and psychosis.
Child and adolescent bipolar disorder is often co-morbid with attention deficit
and conduct disorders. For children and adolescents in a current manic episode,
1-year recovery rates of 37.1% and relapse rates of 38.3% have been reported. In
a 5-year prospective follow-up of adolescents experiencing bipolar disorder,
relapse rates of 44% were found. Despite the severity and chronicity of this
disorder in children and adolescents and its devastating impact on social,
emotional, and academic development, treatment research has lagged far behind
that of adult bipolar disorder.
Although there is more information available about the use of
lithium and
divalproex in children and adolescents with bipolar disorder, other medication
treatment options include atypical antipsychotics,
carbamazepine, and
combinations of these medications.
Treatment with a maintenance agent should continue for a minimum of 18 months
after stabilization of a manic episode. There is evidence that ultimate
stabilization takes a number of years. In addition, lithium discontinuation has
been shown to increase relapse rates in adolescents with bipolar disorder:
relapse occurred within 18 months in 92% of those who discontinued lithium
versus 37% of those who continued lithium . Consequently, medication
discontinuation should be done gradually at a time when there are no major
anticipated stressors.
Psychiatric co-morbidity may complicate the diagnosis and treatment of
bipolar disorder in children and adolescents. The presence of
ADHD, especially
in children and adolescents, confounds the assessment of mood changes in
patients with bipolar disorder. Early manifestations of mania and hypomania can
be particularly difficult to distinguish from the ongoing symptoms of ADHD.
Careful tracking of symptoms and behaviors is helpful. In addition, the presence
of ADHD is associated with higher rates of learning disabilities, which should
be addressed in treatment planning.
Youths with bipolar disorder are at greater risk for substance use disorders.
Co-morbid substance use has been shown to complicate the course of bipolar
disorder and its treatment. Short-term treatment with lithium and divalproex may
be useful in these conditions. However, in a 2-year follow-up of hospitalized
manic adolescents, the bipolar disorder patients who continued to abuse
substances had more manic episodes and poorer functioning than early-onset
bipolar disorder patients who did not exhibit co-morbid substance abuse. In
contrast, cessation of substance use was associated with fewer episodes and
greater functional improvement at the 4-year follow-up point.
5. Geriatric patients
In patients over 65 years of age, prevalence rates of bipolar disorder range
from 0.1% to 0.4%. In addition, 5%-12% of geriatric psychiatry admissions are
for bipolar disorder. Relative to patients with onset of mania at a younger age,
those with onset at an older age tend to have less of a family history of
bipolar disorder. They may also have longer episode durations or more frequent
episodes of illness. Of individuals with onset of mania at older ages, one-half
have had previous depressive episodes, often with a long latency period before
the first manic episode.
Manic syndromes in geriatric patients may also be associated with general
medical conditions, medications used to treat those conditions, or substance
use. The new onset of mania in later life is particularly associated with high
rates of medical and neurological diseases. Right hemispheric cortical or
subcortical lesions are especially common. Relative to elderly patients with
multiple episodes of mania, geriatric patients with a first episode of mania
have a higher risk of mortality. Therefore, any patient with a late onset of
manic symptoms should be evaluated carefully for general medical and
neurological causes.
General principles for treating geriatric mania are similar to those for
younger adults. Older patients will usually require lower doses of medications,
since aging is associated with reductions in renal clearance and volume of
distribution. Concomitant medications and medical conditions may also alter the
metabolism or excretion of psychotropic medications. Older patients may also be
more sensitive to side effects because of greater end-organ sensitivity. Many
elderly patients tolerate only low serum levels of lithium (e.g., 0.4-0.6 meq/liter)
and can respond to these levels. Those who tolerate low serum lithium levels but
who are not showing benefit should have slow dose increases to yield serum
levels in the usual therapeutic range.
Older patients may be more likely to develop cognitive impairment with
medications such as lithium or benzodiazepines. They may also have difficulty
tolerating antipsychotic medications and are more likely to develop
extrapyramidal side effects and tardive dyskinesia than younger individuals.
With some antipsychotics and antidepressants, orthostatic hypotension may be
particularly problematic and increases the risk of falls. Use of benzodiazepines
and of neuroleptics also has been associated with greater risks of falls and hip
fractures in geriatric patients
continue: Concurrent General
Medical Conditions
top .
pages 1
2
3
4 5
6 .
send to friend .
bipolar site
map
Written 4/02. Reviewed: 03/2006
|
del.icio.us
Digg
Furl
Google
StumbleUpon
Yahoo