Transcript Early Age Mania

EARLY AGE MANIA
Anything New ?
Paramjit T. Joshi, M.D.
[email protected]
Children’s National Medical Center
George Washington University School of Medicine
EPIDEMIOLOGY
PEDIATRIC BIPOLAR DISORDERS
• No prevalence studies in pre-pubertal BPD
• 1% lifetime prevalence rate in adolescents
• 5.7% lifetime prevalence of sub-syndromal BPD
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Irritability the rule rather than the exception
Grandiosity, poor judgement
Impaired concentration
DO NOT MEET DURATION CRITERIA
• Adolescents with BPD and sub-syndromal BPD had
significant psychosocial impairment by age 24 years
Lewinshon et al., 2000
As Adults !
• Childhood onset subjects were MOST likely to:
– Have non-remitting BPD
– Prolonged episodes
– Antisocial PD
• Childhood & adolescent onset subjects had
increased prevalence of Drug Use Disorders
• Prevalence of mixed episodes or irritability did
not differ significantly between groups
Goldstein & Levitt, AJP 163:1633-1636, 2006
MANIC EPISODE
DSM - IV: Lasting at least one week with A and
three of B persistent symptoms:
A. Expansive mood / irritability
B. 1. Inflated self-esteem / grandiosity
2. Decreased need for sleep
3. More talkative / pressured speech than normal
4. Racing thoughts / flight of ideas
5. Easily distracted
6. Increase in goal-directed activity
7. Poor judgement or excessively involved in
pleasurable but risky activities, hypersexuality
Core Symptoms of Bipolar Disorder
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Extremely elevated mood
Racing thoughts / flight of ideas
Decreased need for sleep
Grandiosity
Poor judgement:
• hypersexuality
• daredevil acts
• silliness, laughing
• uninhibited people seeking
BPD vs ADHD
MANIA ITEMS
Irritability
Grandiosity **
Elated mood **
Dare devil acts *
Uninhibited people
seeking
Silliness / laughing
Flight of ideas *
Accelerated speech
Hypersexuality **
BPD(%)
97
85
87
70
68
ADHD(%)
72
7
5
13
21
65
66
97
45
21
10
78
8
Robert Post et al., Presented at the 3rd Annual NIMH P-BPD Conference, 2005
Rx of Early Age Mania (TEAM STUDY)
Funded by the NIMH (2003-2009)
AIM:
• To investigate the effectiveness of medications
for C&A who have DSM-IV BP-1 (manic or
mixed phase) mania
• 540 subjects aged 6-15 years of age
• Narrow BP phenotype based on WASH-U
K-SADS interviews video-taped and reviewed
by the coordinating site for consensus
diagnosis
RESEARCH PLAN
• Investigate the effectiveness of Lithium (Li),
Valproate (Val) and Risperidone (Rsp) as
monotherapy and as add-on agents for
childhood BP-1 (manic or mixed phase) mania
• Explore the effects of psychosocial factors
(e.g. parental warmth, parental BPD, family
tension), discontinuation, compliance and
outcome
TREATMENT OF EARLY AGE MANIA (TEAM) FLOW CHART
Screening for Eligibility
Baseline Assessments
Ineligible Given
Clinical Referrals
Baseline Assessments
If eligible, assigned to one of Three Strata
8 Week Protocol
Ineligible Given
Clinical Referrals
Stratum One
Drug free strategy
Stratum Two
Stratum Three
Add-on strategy
Cross-taper strategy
Baseline: On one drug with Baseline: On one drug with
partial response
poor response
Baseline: Antimanic drug free Randomize: To add-on one Randomize: To Cross-taper
of two other drugs
one of two other drugs
Randomize: Li, Val, Rsp
Partial Responders
Re-randomize: Within stratum two
for another 8 weeks
Poor Responders
Re-randomize: Within stratum three
for another 8 weeks
Subjects Randomized: (All sites 315)
AT CNMC:
• Total number of baseline subjects = 101
– Males 74%
– C: 46%
AA: 44%
H: 5%
Other: 5%
• Number of randomized subjects = 67
– Strata 1 = 48
– Strata 2 = 5
– Strata 3 =14
(Lost 34 due to either lack of diagnostic consensus
agreement between sites or not meeting diagnostic criteria
at the completion of the baseline interviews)