What medications are used to treat bipolar disorder in children?

Medications for Bipolar Disorder in Children

For children with bipolar disorder, FDA-approved second-generation antipsychotics (aripiprazole, asenapine, olanzapine, quetiapine, and risperidone) are the first-line treatments for manic/mixed episodes, while lithium and valproate remain important alternatives. 1

First-Line Medications for Pediatric Bipolar Disorder

For Manic/Mixed Episodes:

• Second-generation antipsychotics (SGAs):
  • Aripiprazole
  • Asenapine
  • Olanzapine
  • Quetiapine
  • Risperidone

These medications have FDA approval for treating manic/mixed episodes in pediatric bipolar disorder and are often preferred as monotherapy 1.

For Depressive Episodes:

• Lurasidone
• Olanzapine-fluoxetine combination

Both have FDA approval for treating bipolar depression in pediatric patients 1.

Alternative Mood Stabilizers

• Lithium: The traditional gold standard for bipolar disorder, effective for prophylaxis of manic, depressive, and suicidal symptoms 2

  • Dosage: Should be initiated at lower doses in children compared to adults
  • Requires regular monitoring of serum levels
  • Safe and effective for children, though some studies show risperidone and quetiapine may be superior in certain aspects 2

• Valproate: Often used as an alternative when lithium is not tolerated 3

  • Particularly useful for rapid cycling
  • Requires monitoring of serum levels and liver function

• Lamotrigine: Particularly effective for depressive episodes 3

  • Should be initiated at 25 mg/day and titrated slowly
  • Has minimal sexual and metabolic side effects

Special Considerations for Children

1. Dosing: Starting doses should be lower in children than adults 4

   • For example, olanzapine in adolescents should start at 2.5-5 mg once daily (compared to 5-10 mg in adults) 4

2. Side Effect Profile: Children and adolescents are more susceptible to certain side effects 4

   • Weight gain
   • Metabolic changes (increased cholesterol, triglycerides, LDL)
   • Sedation
   • Elevated prolactin levels
   • Hepatic enzyme elevations

3. Monitoring Requirements:

   • Regular weight and BMI checks
   • Metabolic monitoring (glucose, lipids)
   • Liver function tests
   • Thyroid function (especially with lithium)
   • Serum drug levels for lithium and valproate

Polypharmacy in Pediatric Bipolar Disorder

Many children with bipolar disorder receive multiple medications (mean of 3.0-3.4 medications per patient) 5. This reflects the complex nature of the disorder and frequent comorbidities:

• 68% of patients are treated for comorbid disorders 5
• Only 23% of patients are managed with monotherapy 5

Treatment Approach by Episode Type

Manic/Mixed Episodes:

1. First choice: Second-generation antipsychotic monotherapy
2. Alternative: Lithium or valproate
3. For inadequate response: Consider combination therapy

Depressive Episodes:

1. First choice: Lurasidone or olanzapine-fluoxetine combination
2. Alternative: Lamotrigine (particularly effective for depression)

Adjunctive Therapies

Medication should be combined with psychosocial interventions:

• Family-Focused Treatment for Adolescents (FFT-A) is strongly recommended 3
• Cognitive Behavioral Therapy
• Psychoeducation about medication adherence
• Regular sleep schedule and stress reduction

Common Pitfalls to Avoid

1. Misdiagnosis: Symptoms of bipolar disorder can overlap with ADHD and other conditions
2. Inadequate monitoring: Regular monitoring of side effects and drug levels is essential
3. Triggering mania with antidepressants: SSRIs should be used cautiously and generally with mood stabilizers
4. Ignoring comorbidities: ADHD, anxiety, and other conditions often co-occur and may require additional treatment
5. Underestimating side effects: Children may be more vulnerable to metabolic and endocrine side effects of medications

The treatment of pediatric bipolar disorder requires careful medication selection, appropriate dosing, and vigilant monitoring for efficacy and side effects, with special attention to the increased vulnerability of children to certain adverse effects.