Would a mood stabilizer like Abilify (aripiprazole) or Trileptal (oxcarbazepine) be a reasonable option for a 13-year-old with mood swings, irritability, self-injurious behavior, suicidality, and anxiety?

From the Guidelines

Mood stabilizers like Abilify (aripiprazole) or Trileptal (oxcarbazepine) could be reasonable options for a 13-year-old experiencing mood swings, irritability, self-injurious behavior, suicidality, and anxiety, but only under careful psychiatric evaluation and supervision. Aripiprazole is FDA-approved for pediatric bipolar disorder and irritability associated with autism at doses typically starting at 2-5mg daily, while oxcarbazepine might be used off-label starting at 150-300mg twice daily with gradual increases, as noted in the practice parameter for the assessment and treatment of children and adolescents with bipolar disorder 1. These medications work by modulating neurotransmitters like dopamine, serotonin, and glutamate to stabilize mood and reduce impulsivity.

However, treatment should always begin with a comprehensive psychiatric assessment to determine the underlying cause of symptoms. Any medication approach should be part of a broader treatment plan including therapy (such as cognitive behavioral therapy or dialectical behavior therapy), safety planning for suicidal thoughts, and regular monitoring for side effects. Dialectical behavioral therapy (DBT) has shown promise in reducing depressive symptoms and suicidality in adolescents with bipolar spectrum disorders, as demonstrated in a small RCT comparing DBT versus standard outpatient care 1.

Key considerations for treatment include:

• Starting with a comprehensive psychiatric assessment to determine the underlying cause of symptoms
• Using medication as part of a broader treatment plan that includes therapy and safety planning
• Monitoring for potential adverse effects, including sedation, weight gain, metabolic changes with Abilify, or dizziness, nausea, and hyponatremia with Trileptal
• Regular follow-up appointments every 2-4 weeks initially to monitor response and adjust treatment as needed
• Considering DBT as a potentially efficacious treatment for reducing depressive symptoms and suicidality in adolescents with bipolar spectrum disorders 1.

From the FDA Drug Label

The pooled analyses of placebo-controlled trials in children and adolescents with MDD, Obsessive Compulsive Disorder (OCD), or other psychiatric disorders included a total of 24 short-term trials of 9 antidepressant drugs in over 4400 patients There was considerable variation in risk of suicidality among drugs, but a tendency toward an increase in the younger patients for almost all drugs studied The risk differences (drug vs. placebo), however, were relatively stable within age strata and across indications. Patients, their families, and their caregivers should be encouraged to be alert to the emergence of anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, mania, other unusual changes in behavior, worsening of depression, and suicidal ideation, especially early during antidepressant treatment and when the dose is adjusted up or down.

Mood Stabilizers like Abilify or Trileptal are not a straightforward option for a 13-year-old with mood swings, irritability, self-injurious behavior, suicidality, and anxiety.

• The use of these medications, especially in pediatric patients, requires careful consideration of the risks and benefits.
• Close monitoring is necessary to watch for the emergence of suicidal thoughts or behavior, as well as other unusual changes in mood or behavior.
• The FDA drug labels for these medications do not provide clear guidance on their use in pediatric patients with this specific set of symptoms.
• Alternative treatment options may be available, and a thorough evaluation by a qualified healthcare professional is necessary to determine the best course of treatment 2, 3, 3.

From the Research

Mood Stabilizers for Adolescents

• The use of mood stabilizers in adolescents is a complex issue, with various options available, including lithium, anticonvulsants, and second-generation antipsychotics 4.
• For bipolar disorder in adolescents, lithium has been licensed in France (from the age of 16) and in the USA (from the age of 12), with indications for acute mania and preventive treatment 4.
• Anticonvulsants, such as valproate, have been recommended by the American Academy of Child and Adolescent Psychiatry (AACAP) as a first-line treatment for mania, but their use is cautioned due to potential side effects, including teratogenic and endocrine effects 4.
• Second-generation antipsychotics, such as aripiprazole, have been approved for the treatment of bipolar disorder in adolescents, with recommended doses usually lower and titration slower than for adults 4.

Abilify (Aripiprazole) and Trileptal (Oxcarbazepine)

• Aripiprazole has been shown to be effective in the treatment of refractory mood disorders, including bipolar disorder, with a case series demonstrating complete remission of affective symptoms in three patients 5.
• Oxcarbazepine, also known as Trileptal, is an anticonvulsant that has been used as a mood stabilizer, but its efficacy and safety in adolescents have not been extensively studied 4.
• The AACAP recommends second-generation antipsychotics, such as aripiprazole, as a first-line treatment for bipolar disorder, while anticonvulsants, such as oxcarbazepine, are not recommended as a first-line treatment due to limited evidence 4.

Suicidality and Anxiety

• Suicidal behavior is strongly associated with depression, and long-term treatment with lithium has been shown to have preventive effects on suicidal behavior 6.
• Antisuicidal effects of anticonvulsant mood stabilizers, such as oxcarbazepine, appear to be less than with lithium, and further evaluation is needed for potential antisuicidal effects of atypical antipsychotics, such as aripiprazole 6.
• Anxiety is a common comorbidity with mood disorders, and adequate management of suicidal risks in mood disorder patients requires comprehensive, clinically skillful monitoring and timely interventions 6.