Medications for Treating Bipolar Disorder in Teenagers
For teenagers with bipolar disorder, second-generation antipsychotics (particularly aripiprazole, risperidone, quetiapine, and olanzapine) are recommended as first-line treatments, with lithium also being an FDA-approved option for adolescents aged 12 and older. 1, 2
First-Line Medication Options
Second-Generation Antipsychotics
- Aripiprazole: FDA-approved for acute mania from age 10 in the US and age 13 in France 2
- Risperidone: FDA-approved from age 10 for acute mania in the US 2
- Quetiapine: FDA-approved from age 10 for acute mania in the US 2
- Olanzapine: FDA-approved from age 13 for acute mania in the US 1, 2
Lithium
- FDA-approved for adolescents from age 12 in the US and age 16 in France 2
- Indicated for both acute mania and preventive treatment 2
- Despite strong evidence supporting its efficacy, lithium is often underutilized in adolescents 2
- Target lithium level: 0.8-1.2 mEq/L (measured 12 hours after last dose) 2
Medication Considerations
Dosing Strategies
- For lithium: Starting at 300mg three times daily, with weekly increases of 300mg until response or side effects occur 3
- For antipsychotics: Lower doses and slower titration than adults 2
- Olanzapine requires careful monitoring due to significant metabolic side effects 4
Monitoring Requirements
Regular monitoring should include:
- Weight and BMI
- Blood pressure
- Fasting glucose and lipids
- Serum medication levels (especially for lithium)
- Thyroid, renal, and liver function
- Complete blood count
- Pregnancy tests when applicable 1
Special Considerations for Adolescents
Side Effect Profile
- Adolescents are more susceptible to certain side effects compared to adults:
Medication Adherence
- Compliance is especially challenging in adolescents (less than 40% in some studies) 2
- Contributing factors include:
- Poor acceptance of diagnosis
- Strained relationships with adults/authority figures
- Impulsivity and risk-taking behaviors 2
Alternative and Adjunctive Treatments
Anticonvulsants
Valproate: Recommended by some guidelines for mania, but not FDA-approved for adolescents 2
- Caution: Should be avoided in females of childbearing age due to teratogenic risks 2
Lamotrigine: May be beneficial for bipolar depression in adolescents 2, 5
- Not FDA-approved for this age group
- Requires careful titration to minimize risk of serious skin reactions
Combination Therapy
- Often necessary for optimal symptom control 5
- Lithium plus lamotrigine may provide effective prevention of both mania and depression 5
- SSRIs should only be used in combination with mood stabilizers (lithium or valproate) for depressive episodes 1
Treatment Duration and Discontinuation
- Maintenance treatment with lithium or valproate should continue for at least 2 years after the last episode 1
- Gradual tapering is essential when discontinuing medications 1
- Any medication changes should be accompanied by psychoeducation, cognitive behavioral therapy, and family interventions 1
Common Pitfalls to Avoid
Misdiagnosis: Bipolar disorder is often initially misdiagnosed, delaying appropriate treatment by an average of 9 years 6
Monotherapy with antidepressants: Can trigger manic episodes and is not recommended 6
Inadequate monitoring: Failure to regularly assess metabolic parameters can lead to significant health complications 1
Premature discontinuation: Stopping medications too early increases relapse risk 1
Overlooking comprehensive care: Medication should be part of a total treatment program including psychological, educational, and social interventions 4
Remember that bipolar disorder typically begins between ages 15-25, with depression often being the initial presentation 6. Early diagnosis and appropriate medication management are crucial for improving long-term outcomes in adolescents with bipolar disorder.